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COPYRIGHT DEPOSIT. 



COMPENDIOUS SYSTEM 



OF 



MIDWIFERY, 



CHIEFLY DESIGNED TO FACILITATE THE 



INQUIRIES 



OF THOSE WHO MAY BE PURSUING THIS BRANCH OF STUDY. 



ILLUSTRATED BY OCCASIONAL CASES. 



WITH THIRTEEN ENGRAVINGS. 



BY 

WILLIAM P. DEWEES, M.D., 

r-ECIFRER ON VIDWIFERT: 
MKMBKR OF THE AMERICAN PHILOSOPHICAL SOCIETY, &C. &C. 




PHILADELPHIA 



R§52*\ 






Eastern District of Pennsylvania, to wit: — 

BE IT REMEMBERED, that, on the thirteenth day of October, in the forty-, 
ninth year of the Independence of the United States of America, A. D. 1824, 
William P. Dewees, M. D., of the said district, hath deposited in this office the 
title of a book, the right whereof he claims as Author, in the words following, to 
wit: — 

"A Compendious System of Midwifery, chiefly designed to facilitate the inquiries 
of those who may be pursuing this branch of study. Illustrated by occasional 
Cases. With thirteen Engravings. By William P. Dewees, M. D., Lecturer 
on Midwifery, Member of the American Philosophical Society, &c, &c. 

In conformity to the Act of Congress of the United States, entitled, "An Act 
for the Encouragement of Learning, by securing the Copies of Maps, Charts, and 
Books, to the Authors and Proprietors of such Copies, during the times therein 
mentioned" — and also to the Act, entitled, "An Act supplementary to an Act, 
entitled, 'An Act for the Encouragement of Learning, by securing the Copies of 
Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during 
the times therein mentioned,' and extending the benefits thereof to the arts of 
designing, engraving, and etching Historical and other Prints." 

D. CALDWELL, 
Clerk of the Eastern District of Pennsylvania. 



Copyright renewed according to Act of Congress, in the year 1852, by 

BLANCHARD & LEA, 

in the Clerk's Office of the District Court for the Eastern District of the State of 

Pennsylvania. 



TO 
PHILIP S. PHYSICK, M. D„ 

PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 

MY EARLY AND FAITHFUL FRIEND. 

* 

THE SPLENDOUR OF WHOSE PROFESSIONAL REPUTATION 

IS ONLY EXCEEDED BY 

THE PURITY OF HIS PRIVATE CHARACTER, 
THIS WORK, 

THE RESULT OF MY INQUIRIES, OBSERVATIONS, AND REFLECTIONS, ON AN IMPORTANT 

SUBJECT, 

IS AFFECTIONATELY INSCRIBED, BY 

Wm. P. DEWEES. 






CONTENTS. 



Introduction 



CHAPTER I. 



Sect. I. Of the Pelvis . 

II. Of the Sacrum .... 

III. Of the Coccyx . 

IV. Of the Ossa Innominata 

V. Of the separation of the bones of the Pelvis 
VI. Of the deformity of the Pelvis . 
VII. Examination of the Pelvis . . 



PAGE 

11 



17 

18 
19 
19 
20 
26 
34 



Of the Child's Head 



CHAPTER II. 



36 



CHAPTER m. 

Of the Genital Organs 

Sect. I. Of the Internal Organs . 

II. Of the Uterus and its Dependencies 

CHAPTER IV. 

Of the Efficient and Final Cause of the Menses 
Sect. I. Of Lunar Influence . 

II. The General Plethora Doctrine . 

III. Topical Congestion . 

IV. Final cause 



39 
42 
43 



52 
56 
56 

58 
60 



CHAPTER V. 

Of Conception ....... 62 

Sect. I. Graviditas in Uteri Substantia, or Graviditas Interstitialis . 64 

CHAPTER VI. 

Of the Changes produced by Conception r . . 64 

Sect. I. The Membranes . . . . . .68 

II. The Placenta ...... 71 

III. Foetal Circulation . . . . . .73 

IV. Of the Changes which take place in the Uterus from Impreg- 

nation . i * » . . . 75 

CHAPTER VII. 

Of the Development of the Foetus i . . . 78 



Of the Action of the Uterus 



CONTENTS. 



CHAPTER VIII. 



CHAPTER IX. 



Of Displacements of the Uterus 
Sect. I. Of Prolapsus from Pregnancy . 
II. Retroversion of the Uterus . 
III. Of the Obliquities of the Uterus 

CHAPTER X. 

Of the Term of Utero-Gestation 



CHAPTER XI. 



Cause of Labour 



CHAPTER XII. 
Of Labour ....... 

Sect. I. Of Rigours, &c. .... 

II. Frequent inclinations to make water, Tenesmus, &c. 
III. Affections of the Uterine System, in particular 

a. Subsiding of the Abdominal Tumour 

b. Secretion of Mucus ..... 

c. Dilatation of the Os Uteri 

a. Contraction of the Longitudinal Fibres 

b. Contraction of the Circular Fibres 

c. Of the Simple Contraction . 

d. Of the Compound Contraction . 

e. Of the Tonic Contraction and its Effects 
/. Of the Spasmodic or Alternate Contraction, and its Effects 

CHAPTER XIII. 

The Manner in which the Os Uteri is opened 

CHAPTER XIV 

Conduct during Labour . 

Sect. I. What may be necessary for the Child 
II. Unassisted delivery of the Placenta 

III. Of Putting to Bed . 

IV. Of After-pains . 
V. Regimen during the Month, &c. 

VI. Of the Lochia . 

Excessive Lochia 
VII. Attention necessary to the Child 

a. Of washing the Child 

b. The dressing of the Navel . 

c. Purging of the Meconium, &c 
(/. Of the Retention of Urine 

VIII. Of Food for the Child 

CHAPTER XV. 

Of Natural, or Unassisted Labour 

CHAPTER XVI. 

Of the Presentations of the Head, and their Causes 

1* 



V 

PAGE 

89* 



93 

94 

94 

102 



110 



125 



142 
142 
143 
144 
144 
145 
147 
147 
148 
148 
149 
149 
150 



152 



156. 

160 

167 

168 

163 

174 

177 

178 

181 

181 

181 

183 

184 

186 



188 



191, 



VI 



CONTENTS. 



Sect. I. First Presentation, and its Mechanism 

II. Character and Mechanism of the Second Position 

III. Third Position 

IV. : Fourth Position ■ 

V. Fifth Position 

VI. , Sixth Position . 



PAGE 

193 
195 
195 
195 
199 
200 



PART II. 

Of Labours, in which the Child presents the Vertex, but rendered diffi- 
cult, or preternatural .... 



201 



CHAPTER XVII. 

Causes of Preternatural Labours 
Sect. I. Of Flooding . 
II. Of Convulsions 

III. Of Syncopes 

IV. Of Hernia . 
V. Of Obliquity of the Uterus 

VI. Of Partial Contractions of the Uterus 
VII. Of Compound Pregnancy 
VIII. Of Prolapsus of the Umbilical Cord, &c. 
IX. Of too short a Cord 
X. Of the Bati Position of the Head, though the vertex may pre- 
sent ........ 

a. Of the Bad Position of the Vertex . 

b. Of the Chin departing too early from- the Breast 

c. Cases in which the Face presents 

d. Presentations of the Head and Hand 
XI. Of Exhaustion . 

XII. Of Hemorrhage from other parts than the Uterus . 



201 
202 
203 
204 
206 
207 
207 
211 
212 
212 

212 
213 
214 
218 
221 
222. 
226 



CHAPTER XVIII. 

Rules for Conducting a Preternatural Labour . 
Sect. I. Position of the Woman for Turning 



227 

228 



CHAPTER XIX. 

The Mode of Operating in each Presentation of the Head 
Sect. I. First Presentation .... 

II. Second do. ..... 

III. Third do. . . , 

IV. Fourth and Fifth do. . 
V. Sixth do., 



233 
233 
234 
234 
235 
235 



PART III. 

Where it is necessary to use Instruments which do no injury to Mother 
or Child 



23: 



CHAPTER XX. 



$£the Forceps . 



23.7 



CONTENTS. VU 

PAGE 

Sect. I. General rules for the use of the Forceps . . . 239 

a. Of those which regard the woman . . . 239 

b. Of the Condition of the Uterus and Soft Parts . . 240 

c. Application, and mode of Action of the Forceps . . 241 

a. Of Compression ...... 250 

b. Compression and Traction .... 252 

d. Mode of Acting after Application .... 252 
II. Recapitulation ...... 254 

III. General Observations upon the Forceps . . . 255 

CHAPTER XXL 

Of the specific Application of the Forceps .... 257 

Sect. I. a. Application in the First of these Positions . . . 258 

II. b. Second .... 259 

III. c. Third . . . . .259 

IV. d. Fourth .... 260 

V. c. Fifth . . . . .260 

VI. /. Sixth .... 261 

VII. g. Seventh . . ... .261 

CHAPTER XXII. 

General remarks on the Use of the Forceps, when the head is above the 

Superior Strait ....... 262 

CHAPTER XXIII. 

Of the Locked or Impacted Head ..... 263 

Sect. I. Of the Causes, Signs, and Accidents of the Locked Head . 264 

II. Indications in the Locked Head .... 265 

III. Method of using the Forceps in the Locked Head . . 266 

CHAPTER XXIV. 

Of the use of the Forceps in Face Presentations . . . 267 

CHAPTER XXV. 

Of Presentations of the Breech ..... 269 

Sect. I. Species of Breech Presentations . . • . . 271 

II. a. Mechanism of First Breech Presentations . . . 271 

III. b. Second do. ... 272 

IV. c. Third do. . . . 272 

V. d. Fourth do. ... 272 

CHAPTER XXVI. 

Causes which may render Presentations of the Breech Preternatural . 273 

a. First degrees of advancement .... 274 

b. Second do. ...... 276 

c. Third do. ..... 276 

Sect. I. Position of the Child ...... 278 

II. Size of the Breech ..... 279 

III. Mode of bringing down the Feet in the first Breech Presenta- 
tions ....... 279 

IV. Mode in Second Position of the Breech . . . 280 
V. Third do 280 

VI. Fourth do. i 281 



Vlll CONTENTS. 

PAGE 

CHAPTER XXVII. 

On the use of the Forceps, when the body is delivered, and the head 

retained . . . . . . • 282' 

Sect. I. Cases proper for the Forceps . . . . . 288 

a. Mode of operating in First Case . . . 288 

b. Second do. ..... 289 

CHAPTER XXVIII. 

Of the Presentations of the Feet ..... 289 

Sect. I. Species of Feet Presentations .... 290 

II. Preternatural Labours when Feet present . . . 291 

HI. Mode of Acting in the First and Second Presentations .. 292 

IV. Third and Fourth do. . . 293 

CHAPTER XXIX. 

Presentations of the Knees ...... 296 

Sect. I. Causes which render Presentations of the Knees preternatural 297 

II. Mode of Operating in Presentations of the Knees . . 298 

CHAPTER XXX. 

Of Tedious Labour ........ 298 

Sect. I. Of the Want of Contractile Force . . . . 300 

Cases ....... 300 

II. Of Rigidity, &c. of the Soft Parts, as the cause of Tedious 

and Preternatural Labour ..... 302 

Of the Species of Rigidity of the Os Uteri . . 308 
Rigidity of the first Kind . . .. . .308 

Var. 1, . 308 

2, . . . . .309 

3, .... 309 

III. Cicatrices, or other Imperfections arising from Local Injuries 311 

Cases . . . . . . . 311 

Relative Rigidity . . . . . .317 

IV. Tonic Rigidity; or Rigidity from the premature Escape of the 

Waters . . . . . . .318 

Sect. V. and VI. Over-distention of the Uterus, and the membranes too 

dense, as a cause of Tedious Labour . . 319 

CHAPTER XXXI. 

Hemorrhage from the situation of the Placenta over the mouth of the 

Uterus ....... 322 

Sect. I. Where the Uterus is but little opened, and is very rigid . 333 

II. When but little opened, but disposed to dilate . . 335 

III. Opened to some extent, but very unyielding . . 336 

IV. Where opened to the same extent but soft, . . . 338 
V. Where fully dilated ..... 338 

A case of fatal Hemorrhage at the Seventh Month of Utero- 
gestation, from the Placenta being placed over the mouth 
of the Uterus, together with remarks upon it, and several 
other modes of treating Uterine Hemorrhage . . 348 
VI. Causes of Uterine Inertia ..... 356 
VII. Hemorrhage, before the Placenta is expelled . . 356 
a. I. Where there is a partial separation, but the Uterus enjoy- 
ing some tonic power . . . . . 357 



CONTENTS. IX 

PAGE 

b. II. Where there is a partial separation, but the Uterus possess- 

ing very little or no tonic power . . . 358 

c. III. Where there is a partial saparation of the placenta, while 

the remaining portion is too adherent, and the Uterus 

contracts but feebly ..... 362 

d. IV. Where every thing is as at III. except that the Uterus enjoys 

its full power ...... 364 

e. V. Where there is an entire or partial separation, but the Uterus 

in a state of exhaustion or syncope . . . 365 

/. VI. Where there is either a partial or complete separation of the 

placenta, and where the body and fundus are in a state of 

Inertia, while the neck enjoys its tonic powers . . 368 

VIII. Flooding after the expulsion of the Placenta . . 370 

IX. On the means for preventing Flooding . . . 371 

CHAPTER XXXII. 

Of the Assisted delivery of the Placenta .... 375 

Sect. I. Mode of acting in Retention from want of Tonic Power . 376 

II. Retention from too firm adherence .... 376 

a. Mode of acting in this Case .... 377 

III. Of the Delivery of the Encysted Placenta . . . 379 

a. Mode of operating in this Case . ... . 380 

IV. On the enclosed and partially protruded Placenta . . 381 

Mode of acting in each Case .... 382 
V. Of the delivery of the Placenta, when the cord is broken, or is 

very feeble ...... 383 

a. The signs by which the Placenta may be detected , 384 

b. Mode of acting in this case . . . 385 

CHAPTER XXXIII. 

Of Puerperal Convulsions ...... 336 

Cases ........ 391 

CHAPTER XXXIV. 

On the Inversion of the Uterus ..... 399 

Cases ......... 416 

CHAPTER XXXV. 

Of Twins, &c. ........ 420 

a. On the Management of the Placenta . . . 430 

CHAPTER XXXVI. 

Of Preternatural labours ...... 432 

CHAPTER XXXVII. 

Of the Presentation of the Arm and Shoulder . . . 433 

Sect. I. Of the Condition of the Uterus .... 438 

II. Of the Situation of the Arm and Shoulder within the Pelvis 440 

a. The Manner of Acting, if the Child be living . . 440 

b. Of Spontaneous Evolution , 442 

c. Mode of Acting, if the Child be dead . . . 444 

CHAPTER XXXVIII. 

On Presentations, with the falling down of the Umbilical Cord . 448 

CHAPTER XXXIX. 

Of the Rupture of the Uterus ..... 457 

Gastrotomy ...... k 467 



CONTENTS. 



PART IV. 



CHAPTER XL. 
Deformity of the Pelvis ..... 

Sect. I. Of Turning in a Deformed Pelvis, as a means of saving the 

Child's Life 

II. Of the Forceps in a Deformed Pelvis 

III. Of Cephalotomy , 

Observations, &c, on Eliaabeth Sherwood's Case, as 
related by Dr. Osbom 

IV. Of the Caesarean Operation .... 

a. Mode of Performing it 

b. Treatment after the operation 
V. On Premature Delivery .... 

VI. Section of the Pubes ..... 

VII. Regimen ...... 



PUBLISHERS ADVERTISEMENT. 



527 



CHAPTER XLI. 

Monstrosity and Accidental Deformity .... 

CHAPTER XLII. 

Uncertainty of the Child's Death . . . . 

CHAPTER XLIII. 
On the Secale Cornutum, or ergot ..... 529 



PAGE 



On Deliveries performed by Cutting Instruments, applied either to the 
the Child or Mother .;.... 469 



469 

470 
472 
475 

485 
490 
501 
506 
508 
517 
523 



The present Edition of this valuable work contains the revisions 
and additions of the author made by him a short time previously to 
his death. 

Philadelphia, January, 1847. 



INTRODUCTION. 



It has often been declared, that labour, being a natural act, it 
did not require the interference of art for either its promotion, or its 
accomplishment ; and, consequently, that when this becomes neces- 
sary, it only forms an exception to the rule. This view of the sub- 
ject has had many followers ; and has, from its influence, retarded 
more, perhaps, than any other circumstance, the progress of improve- 
ment in this most important branch of medical science. It so en- 
tirely comported with the theories of the fastidious admirers of na- 
ture ; it so completely coincided with the feelings of those, whose 
supineness made them averse from inquiry ; so effectually apolo- 
gized for ignorance, and so plausibly extenuated the evils arising 
from neglect, or the want of the proper and judicious application of 
skill, as to secure in its favour by far the greater portion of the prac- 
titioners of Midwifery. 

Errors in premises must almost necessarily lead to errors in de- 
duction ; hence the too exclusive reliance on the powers of nature 
to overcome all the obstacles connected with parturition — hence the 
almost total disregard of the first, and most important principles in 
the art of midwifery ! These errors doubtless originated in igno- 
rance ; and were perhaps at first excusable from this cause ; but 
how reprehensible do they become now, since the powers of nature 
are better calculated, and the resources of art better understood ! 
In what light, then, should we view writers, who still inculcate such 
doctrines — teachers who make the whole art of midwifery consist 
in doing nothing ! 

Were the constitutional powers of the system, the physical con- 
formation of the pelvis, and the size of the child's head, always 
and undeviatingly the same ; were the most favourable presentation 
of the child, the best construction, and the most healthy play of the 
powers concerned in this operation, never to be 'assailed by acci- 
dent, or complicated by disease — the opinions of those who contend 



XiU INTRODUCTION. 

for the supremacy of unassisted nature would deserve much, and 
perhaps exclusive attention. But it is too well known, that this 
never has nor never can be the case ; for the powers of nature must 
necessarily have their limits, and consequently the interference of 
art becomes sometimes absolutely necessary. 

I am very far from wishing to be understood, as advocating the 
indiscriminate interference of art during the progress of a healthy 
labour — it is the very reverse of my. opinion, and of my practice ; 
I wish merely to insist that nature is not competent to all exigen- 
cies. For in very many instances, when permitted to proceed with- 
out interruption, and is eventually able to effect her object, the suf- 
ferings of the patient, most probably, might have been very much 
abridged by the judicious interposition of skill. Of this, from long 
experience, I am entirely convinced. 

If this be true in the most healthy or practicable labour, how much 
more important does the judicious and timely application of adventi- 
tious aid become, when it is well known, that the deviations from 
healthy power and structure, are almost constant in their occurrence, 
and almost infinite in their variety. It is the knowledge of these 
aberrations, and the mode of obviating them when necessary, that 
emphatically declare midwifery to be a science — for it has, and must 
have, its principles ; principles, that must not only be known in the 
abstract, but constantly employed; and it is the happy application of 
these fundamental rules, that makes one practitioner superior to ano- 
ther. 

I trust my last assertion will not be considered gratuitous ; for if 
there be a difference in the skill of the practitioners, w T hich most 
certainly there is, it can only arise from a more perfect acquaintance 
with the rules which should govern, the extent of experience, and 
the justness of deduction. But does not this declare there is some- 
thing more to be learnt, than the bare exercise of patience ? What 
practitioner has ever been eminently successful, who has neglected 
the first principles of the art ? He may be extensively employed, 
and tolerably lucky, (for it is nothing more,) without a correct no- 
tion of either the structure of the pelvis, the mechanism of labour, 
or the powers of the uterus; but will he be qualified to act where 
the first is faulty ; the second obstructed ; or the third impaired ? 
will he not, in most instances where either of these conditions ob- 
tain, wait in vain for all-sufficient exertions of nature ? 

Experience, however necessary and important, is not alone suffi- 



INTRODUCTION. Xlll 

cient: a correct foundation must be laid, by the study of first prin- 
ciples ; and with even these, the progress must be slow ; since variety 
in labour is so multiplied. It is only by a happy and well-balanced 
generalization, that the practitioner can arrive at principles ; and it 
is but by judiciously acting upon these, that he can be extensively 
useful. I may safely appeal to the candour of almost any practitioner, 
whether he has not admitted to himself, that had he been better ac- 
quainted with principles at a previous period of practice, he could 
have procured, in certain cases of labour, either a speedier termina- 
tion of it, or a more fortunate issue — I am sure he will answer in the 
affirmative. 

Too much importance can easily be attached to experience alone ; 
for though I consider it a sine qua non to the successful exercise of 
the profession, yet it becomes only decidedly useful in difficult cases, 
when it is based upon the fundamental principles of obstetrics. 
Without an acquaintance with these, every practitioner must act 
empirically ; and this to the too frequent destruction of human life. 
If he be ignorant of all that is essential to be known ©f the well- 
formed and diseased pelvis ; or unacquainted with the various ways 
the head may pass through it, he will be totally incompetent to act,, 
when there is any material deviation from the healthy economy of 
labour. On the one hand, he may rashly suppose, there is no alterna- 
tive but in the use of the crotchet, where a little address might have 
immediately relieved the patient by rectifying the error in presenta-* 
tion ; and on the other, he may negligently and reprehensibly wait 
for the successful operation of nature, until the patient expire. 

In making an estimate of the value of experience alone, I must 
admit that many pursue the safer plan in submitting the case to 
nature ; for I confess that in many cases of desperate appearances, 
he successfully overcomes the dangers. that menace her; but this is. 
only submitting to a choice of evils : while the well-instructed prac- 
titioner would triumph over them by his skill, and spare nature this 
hazardous conflict. That in many instances we should be only the 
silent observers of nature, is unhesitatingly acknowledged ; but I 
must insist, and I am persuaded I shall be supported by every well- 
instructed accoucheur, that it requires no less judgment to determine 
when we should be so, than when it is proper to offer assistance, or 
to take the business entirely out of her hands. 

But the decisions of ignorance do not always result in an entire 
reliance upon the poweri of nature ; they sometimes, and this but 
2 I 



XIV INTRODUCTION. 

too frequently, end in the contrary extreme — in these cases, there is, 
on the part of the practitioner, an overweening desire to aid her ef- 
forts ; and his ill-directed endeavours but too soon eventuate in a 
destructive subversion of her powers. To this we must attribute 
the very many instances of injury that take place in the hands of 
the ill-instructed. Who has not witnessed a labour, which, had it 
been let alone, would have been but an ordinary one, as regards 
duration or severity, converted into one of great hazard, and protract- 
ed duration ? Can such mischievous ignorance be too severely re- 
prehended, or could it be too severely punished ? What has he 
not to answer for, who shall permit a fellow creature to die, w T hen a 
little address or knowledge might have saved her ; or, what is per- 
haps still worse, who shall absolutely destroy her, by ill-judged and 
rude manoeuvres, under the spacious pretence of relieving her, when 
the case should have been trusted to the powers of nature alone. 
A self-sufficient practitioner informed me he thought that he had 
made a great improvement in those cases of delayed labour, where 
the child's head frequently advanced and receded from the outlet of 
the pelvis, owing, as he asserted, to the coccyx losing its faculty of 
receding upon the impulses of the uterus, by introducing two fingers 
into the rectum over the point of the bone, and pulling it back, and 
thus destroying its connexion with the point of the sacrum. He said 
he gained much room from this procedure. He did not take into 
consideration the immense amount of suffering he created, and other 
extreme unpleasant consequences. The patient was obliged ever 
after to use a pierced chair. 

Besides, the peculiar situation of our country, imposes a necessity 
upon every medical student, to become well acquainted with the 
theory of midwifery ; for every one almost must practice it, if he 
pursue the object for which he is educated. A change of manners 
within a few years has resulted in the almost exclusive employment 
of the male practitioner. This was mainly effected by a conviction, 
that the well instructed physician is better calculated to avert danger, 
and surmount difficulties, than the ignorant pretender : but how ill 
is this confidence repaid ! a confidence which costs the female so 
severe a struggle ! Should they submit their welfare, nay their lives, 
to the ill-instructed practitioner, what security have they that they 
shall escape, without having entailed on them a permanent derange- 
ment of organ, or the perpetuation of a harrassing and loathsome 
disease ? 



INTRODUCTION. XV 

In whatever point of view we regard this subject, it must be highly 
interesting to the philosopher, and the philanthropist ; shall it be less 
so, then, to the physician who should be both, and who is more imme- 
diately concerned in its influence ? Shall it be a matter of indifference 
to him, who has almost the control of the future comfort and happi- 
ness of, perhaps, an extensive population, and who shall become, 
as it were, the arbiter of the lives of thousands ? A man of very 
loose morality shudders at the idea of a single murder ; yet an igno- 
rant practitioner of midwifery, may feel no " compunctious visita- 
tions of conscience" for a hundred, committed professionally, from 
ignorance. 

I hope to be credited when I declare, that the present work was 
not undertaken, without due deliberation upon the responsibility 
attached to such an enterprize : and that my aim most honestly was 
to be useful — I have endeavoured to make my experience available 
to the interests of humanity ; and should I even fail to instruct, I 
feel a confidence, I shall not dangerously mislead. 

I have ventured to depart from common usage, in treating of the 
various objects belonging to my subject ; but it is the method I have 
pursued for more than thirty years in teaching ; and to me it appears 
the most natural. That is, to bring under one view all that may belong 
to any particular labour, or class of labours — whether natural, and 
to be trusted to the powers concerned in the operation ; or compli- 
cated, and requiring a departure from this rule ; or when essentially 
bad. I make all the modes of treating it under the various circum- 
stances which may affect it, follow each other without interruption. 

Generally speaking, I have followed Baudelocque's distribution of 
subjects, but not rigorously ; and to him I hold myself indebted for 
nearly all I know ; or, at least, his masterly manner of treating 
every thing connected with this branch of medicine, has enabled 
me to comprehend at once, the seeming intricacies of obstetrics, 
and to profit by bed-side experience. I, therefore, cannot too earn- 
estly recommend the study of his works to such practitioners, as 
well as the student of midwifery, who rnay not have profited already 
by his genius, and his long and well-tried experience. 

I occasionally, in the course of the present work differ from this 
great man; but when I do, it is doubtingly ; and only when a care- 
ful examination of my own experience has produced a conviction 
that it is correct so to do ; accompanied, however, at the same time, 
by a regret, that I am forced to the alternative. 



XVI INTRODUCTION. 

I have added Plates, to represent the different positions of the 
head, that no embarrassment might follow from mere description. 
These, I hope, will prove as acceptable, as I am persuaded they will 
be useful. 

I have materially altered the arrangement of the present edition, 
by removing from it all the Chapters which related to the diseases 
of women and children. My motive for this will be obvious, w T hen 
it is recollected, I have written separate treatises on both these 
subjects, since the first publication of this system. 

I have also added several very important Chapters on subjects 
strictly obstetrical ; together with several new plates, illustrative of 
the topics to which they have reference. In a word, I have attempt- 
ed to make this present edition deserving of the high patronage this 
work continues to receive. 



COMPENDIOUS SYSTEM 



OF 



MIDWIFERY, 



CHAPTER I; 



Section I. — Of tlte Pelvis, 

1. The complete knowledge of the pelvis, as well in its healthy as 
in its diseased state, is essentially necessary to the successful practice 
of midwifery. Had more attention been paid to acquiring an acquaint- 
ance with its natural, and its deranged dimensions, by those who pro- 
fess to practice this important branch of medicine, we should have had 
fewer instances of gross errors in practice, and, of course fewer victims. 
Without understanding the pelvis well, it is impossible that any one 
can safely give assistance where either the operation of turning, or the 
application of the forceps, is required to terminate the labour ; nor can 
the mechanisms of the various presentation's be understood in their 
most simple forms, without a thorough knowledge of it. We hope, 
then, we shall be excused when we say, that no man should be trusted 
to practice obstetrics, who is ignorant of this important assemblage of 
bones. 

2. The pelvis is that structure which is situated below the last 
lumbar vertebra, with which it is by one of its surfaces articulated ; 
and above the superior extremities of the thigh bones, with w T hich it 
is connected, by means of the acetabula. It is composed, properly, 
but of four bones in the adult, state viz., on its posterior and inferior 
part, by the sacrum and coccyx ; and on the lateral inferior and anterior 
parts, by the ossa innominata. But in treating of this structure, it is 
useful and proper to consider its constituent parts, as each is com- 
posed of several others to which appropriate divisions and names have 
been given ; we shall, therefore, pursue this plan, as it has both pro- 
priety and utility to recommend it; and, first, of 

3 



18 THE SACRUM. 



Sect. II. — The Sacrum. 

3. This bone has sometimes been called the false vertebra, because 
it is a kind of continuation of the true ; and because, in the foetal 
state, it may be divided into five portions. The union of these five 
pieces can readily be detected in adult age, by four transverse seams.* 
Its general figure is triangular or pyramidal ; the base of which is up- 
wards, and is connected to the last lumbar vertebra, by a cartilaginous 
intervention. The apex of the triangle or pyramid is below, and has 
the coccyx united to its extremity by means of cartilage. It may be 
divided into four surfaces; namely, an anterior, posterior, and two 
lateral surfaces : its anterior surface is smooth and concave ; while its 
posterior is very rough and convex ; its anterior face is smooth, that 
no obstacles may be offered, or abrasions take place, by the passage 
of the child's head through the cavity of the pelvis ; its posterior is 
studded with processes or eminences, to give greater security and sur- 
face to the various muscles that originate, and that are inserted into 
it ; as, also, to afford greater firmness of connexion to the many liga- 
ments which aid in its union with the ossa innominata. Its lateral 
surfaces are rough or -scabrous ; and are covered in the recent subject 
with cartilage, by means of which they are united to corresponding 
surfaces, offered by the ilia. This bone is pierced on each side by 
four holes, which transmit the sacral nerves. There is also on its 
posterior portion, a canal, along which the spinal marrow is continued. 

4. The manner in which the sacrum is set into the ossa innominata, 
is well calculated to give firmness and security to its position ; as it 
acts, in some measure, as a keystone does to an arch ; this arises 
from two peculiarities of form ; the anterior part of this bone is 
broader than the posterior ; consequently, enters like a wedge be- 
tween the ossa innominata ; this enables it to sustain, without injury 
any force that may operate from within, outwards : the superior por- 
tion is also broader than the inferior ; and, of course is placed pre- 
cisely analogous to the key stone of an arch, by which it is enabled to 
support the superincumbent weight of the body, &c, without yielding. 
We cannot fail to remark, how admirably this arrangement gives sta- 
bility to the whole of the pelvic circle. 

5. The union of the last lumbar vertebra with the base of the sa- 
crum T is permitted to take place in such a manner as to look over, 
and into, the superior opening of the pelvis, so as to form a promon- 

* Velpeau speaks doubtingly of the number of pieces and lines in which the sacrum 
may be divided — why, we are at a loss to understand, as our impression is, that nature 
is uniform in this respect. He says, a sa face (the sacrum) antereure, plus ou moins 
concave, offre, au milieu quotre ou cinq fadeites quadrdngidaries et aittant de lignes 
transversales" p. 3. Baudelocque makes but four lines, as it requires five pieces to 
give four lines when united. He makes but four holes for the transmission of the sa- 
cral nerves, whereas Velpeau makes five. It is true, that the upper portion of the 
coccyx unites with the inferior portion of the sacrum, and thus forms an additional 
hole. In general, however, this is merely a notch in each of these bones, forming 
thus an imperfect foramen, for the transmission of the fifth nerve of the sacrum ; but 
this hole is not proper to (he sacrum. 



COCCYX. 19 

tory ; and hence it is called the projection or promontory of the sa- 
crum. 

6. The length of this bone is usually from four inches, to four and 
a half ; its breadth is about four inches. Its thickness, if measured 
from the middle of its base anteriorly, to the extremity of the supe- 
rior spinous tubercle on its posterior face, is very constantly two inches 
and a half; and we are informed by Baudelocque, (System, page 18, 
par. 35.) that this measurement is so constant, that he did not find it vary 
a line in between thirty and forty pelves, the greater part of which 
were deformed. The concave form of this bone gives a hollo wness 
to a greater part of its length; the depth of this, in a well formed 
bone, is about three-quarters of an inch. 

Sect. III. — The Coccyx. 

7. This appendage to the sacrum is also of a pyramidical form, 
and is about and inch and a quarter in length ; like the sacrum itself, 
it resembles an inverted pyramid ; its base being united with this bone 
by intervening cartilage ; it is formed of three bony portions, whose 
connexion with each other is readily observed by the transverse ridges 
which their union forms. Its connexion is such as to permit of a 
regressive motion ; especially in the earlier parts of life. Lateral mo- 
tion is prevented by the insertion into the sides of this bone, of the 
coccygael muscles ; of parts of the lavatores ani ; and portions of the 
sacro-sciatic ligaments. 

Sect. IV. — The Ossa Innominata. 

8. The other portions of the pelvis are made up of the ossa inno- 
minata ; they constitute the lateral, anterior, and inferior parts of this 
cavity. Each of these is divided into three distinct bones by all the 
writers upon midwifery or anatomy ; and there seems to be propriety 
in this separation ; since they were originally, or in the foetal state, 
distinctly marked as independent bones, though not so clearly defined, 
in adult life ; and in the study of the pelvis, it will contribute to a 
more precise notion of its form and combinations. The os innomi- 
ntaum is then composed of the ilium, ischium, and pubis. 

9. The ilia form the highest lateral portions of the pelvis ; and may, 
with much propriety, be considered as belonging to, and constituting 
a part of, the abdomen, as well as of the pelvis properly so called ; 
the ilium is the largest of the bones now under consideration — its 
superior edge is nearly semicircular, and is almost always tipped with 
cartilage ; this is called the spine of the ilium. It reaches down, 
and forms, with certain portions of the ischium and pubis, the aceta- 
bulum. The external surface of this bone is a little convex, and has 
been named dorsum ; while its internal face is concave, and is called 
costa, or fossa of the ilium. There are four processes usually de- 
scribed as belonging to the ilium ; namely, two anterior, and two 
posterior spinous processes. 



20 THE OSSA INNOMINATA. 

10. The broad, spreading part of this bone is divided from the 
lower portions, by a ridge which commences at its connexion with 
the sacrum ; runs forward, and joins with a similar ridge, sent by the 
os pubis — -this sharp line marks the upper from the lower boundary 
of the pelvis ; and is called the linea ilio pectinea.* 

11. The ischium is the lowest of the three bones ; and, like the 
ilium, forms a part of the acetabulum. From the posterior part of this 
bone, a sharp process runs backward, yet inclining towards the cavity 
of the pelvis, so as rather to diminish its capacity ; to this is attached 
the internal sacro-sciatic ligaments ; it then runs downward, and ter- 
minates in a tuber ; into the inside of which the external sacro-sciatic 
ligament is affixed. From this tuber a bony process is reflected, which 
joins the os pubis. 

12. The os pubis is the smallest of the three bones which consti- 
tute the os innominatum — its largest portion is employed in the for- 
mation of the acetabulum ; it then diminishes in size ; and stretches 
over, to meet a similar portion of the os pubis of the opposite side. 
It now becomes broader and thinner, and sends a branch downwards, 
to unite with the one reflected from the os ischium. The mode of union 
of the bones is such, as to leave a considerable space between them, and 
this space is called foramen ovale, or foramen magnum ischii ; which, 
in the recent subject, is covered by a dense ligamentous membrane, 
and gives origin to the obturator muscles. Nerves and blood vessels 
are transmitted through this membrane by appropriate openings. 

13. The ossa innominata are joined, at their posterior and central 
portions, to the sacrum, by rough corresponding surfaces; these are 
spread over by thin cartilage, and the union secured by strong appro- 
priate ligaments. The anterior junction of these bones is called the 
symphysis of the ossa pubis; but the mode of union is different from 
that which connects their posterior portions — agreeably to Baude- 
locque, nature has paid much more attention to it than to the other 
parts of the pelvis, by sending out, in addition to a proper quantity of 
cartilage, a number of short, but very strong ligaments, which give 
great security to the symphysis. Dr. Wm. Hunter has also given a 
very particular description of the mode of union of the symphysis, in 
the second volume of the Medical Observations and Inquiries, 

14. As it is not in the power of every body to consult and study 
the pelvis from the natural one, it is thought important to give a figure 
of a healthy, well constructed one; that an idea may be formed of its 
general shape and connexions ; and though not as satisfactory as the 
natural preparation, it will, nevertheless, give a pretty correct notion 
of it. (See plates I. and II.) 

Sect. V.^Ofthe Separation of the Bones of the Pelvis. 

15. It would seem, from what occasionally occurs in practice, that 

* This ridge, which, in some subjects, is very sharp, is formed by the superior and 
internal portions of the pubes and ilii. 



OF THE SEPARATION OF THE BOXES OF THE PELVIS. 21 

the bones of the pelvis may separate, notwithstanding the especial care 
that nature has bestowed upon their union. This separation may take 
place in various degrees: from a simple relaxation of the connecting 
media, to an absolute separation. This accident may happen gra- 
dually ; commencing almost with gestation, but not manifesting itself 
with much severity until after delivery ; or it may occur suddenly 
during labour; or just when it is about to be finished. Fortunately 
for the female, it is a disease of rare occurrence ; at least in this 
country ; for we have met with but two decided cases of the kind in 
the course of our practice. 

16. Were we to yield to popular belief, we should be obliged to 
grant, that nature had kindly studied the comfort and safety of the 
female, by endowing the ligaments and cartilages which connect the 
different portions of the pelvis with a capacity to yield to the impulse 
of labour, that the operation might not only be less severe, but safer. 
This opinion is coeval with medical record, and it has been sustained, 
notonly by ingenious reasoning,but by an appeal to observation. The 
respectable names of Pineau and Pare are used in support of it among 
the more remote moderns; and Gardien, in our own time, yields to 
a belief of its advantage. While Baudelocque, Denman, &c, see 
nothing in this supposed provision, but misery to the female who may 
be the subject of it. 

17. We may adduce the following reasons as conclusive against 
this relaxation being a natural provision. 1. It is certain, so far as 
can be determined by the dissection of women who had died during, 
or immediately after labour, that the symphyses were very rarely found 
to have yielded in the slightest degree. ■ Baudelocque tells us, he 
sought for it twenty times in well-constructed pelves after laborious 
labours, as well as in distorted ones, without meeting with scarcely 
one, which could remove all doubts of its existence.* 2. That it is 
not more frequent in the distorted, than in the well-formed pel vise 
now, were it an advantageous provision, it consequently should have 
been more certainly observed in the former. 3. Were it an arrange- 
ment of nature, the means do not seem adequate to the end ; as it 
would require that the extremities of the ossa pubis should be separated 
one inch from each other, to gain two lines, or two-twelfths of an 
inch, in the antero-posterior diameter of the superior strait; an in- 
crease but very rarely sufficient to do good in a contracted pelvis ; 
and unnecessary in a well-formed one ; as the latter is almost con- 
stantly larger than is absolutely necessary in ordinary labours. 4. 
That wherever it has been ascertained to have taken place, even in a 
slight degree, it has never failed to create either temporary, or a per- 
manent inconvenience ; and, where extensive, the most serious evils, 
and even death, have followed.! 

. vol. i. Mr. 
- W t are not a littfc surprised that Dr. Blundell should express himself in the fol- 
lowing terms, without assigning a (single reason for hia belief; namely, that " A (re- 
laxation) occurs in a much higher degree in other gencfa of Hie nximmalia, than m 



22 OF THE SEPARATION OF THE BONES OF THE PELVIS. 

18. Various causes have been assigned for this relaxation or sepa- 
ration of the pelvic bones: 1. Serous depositions in the cellular 
meshes, or interstices of the connecting media. 2. Tumefaction of the 
cartilaginous extremities of the ossa pubis. 3. The child in transitu 
acting like a wedge on the bony circle which bounds the upper strait. 
4. Mechanical violences, as falls, blows, instrumental delivery, &c. 

19. When mere relaxation exists, the symptoms, though pretty 
permanent, are not so violent, as when there is a separation. A 
painful tottering walk, with a greater or less inability to stand, and 
more especially on both feet with equal firmness, mark very cer- 
tainly this condition of the pelvis: and this is sometimes detected 
even before labour. When it happens during labour, it is always 
attended with a painful sensation at the relaxed part, together with 
an inability to exercise the auxiliary powers concerned in this ope- 
ration. This latter circumstance is worthy of notice; as it would 
seem to decide at once, that this yielding is not intended to benefit 
parturient women. When the injury is greater, and a real separa- 
tion has taken place, it has been found, that it is by the destruction 
of the ligamentous tissue which connects the bones, and thus per- 
mits them to retire farther from each other than mere relaxation 
would have done. When it is the symphysis of the pubes which 
suffers this accident, an entire separation of the cartilaginous epi- 
physis from the extremity of the os pubis takes place ; for agreeably 
to Baudelocque, no power is capable of breaking the ligamentous 
substance which connects these two bones. 

20. When this last condition obtains, it is usually followed by a 
melancholy train of evils— pain, inflammation,, suppuration, caries, 
gangrene, and death. 

21. The mode of treatment of these evils is reduced to great sim- 
plicity, though far from equal certainty — the indications are, 1. To 
reduce the parts, as nearly as possible, to their natural position, and 
to secure them thus as effectually as possible. 2. To obviate inflam- 
mation and its consequences, as far as may be practicable. 3. To 
relieve pain. 4. To give strength at a proper time to the system gen- 
erally. 

22. The first indication must be fulfilled by the proper applica- 
tion of bandages; and we are of opinion, that the simple calico roller 
is as effectual as any of the more complicated machinery contrived 
for this purpose. It should be applied as high as the cristse of the 
ilia, and a little below the trochanters of the thighs — its length 
should be so ample, as to secure a number of turns round the parts; 
and it should be drawn sufficiently tight to fulfil the object for which 
it is applied. The patienfmust be confined to a horizontal position, 
and employ her lower extremities as little as possible, at least in the 
beginning of the plan. 

woman* but that even in them some slight relaxation does take place." (Principles 
and Practice of Obstetricy, p. 6.) We would ask for information, has this relaxation 
been proved to take place; as we do not think, without some evidence and that positive, 
this opinion should be received upon the mere ipse dixit of any man; especially as no 
good can be derived from it 



OF THE SEPARATION OF THE BONES OF THE PELVIS. 23 

23. The second indication must be answered by blood-letting, 
leeching, or cupping; a very abstemious vegetable diet must be in- 
sisted on; and the most perfect quiet observed; the bowels should 
be kept free, but the effects of brisk purging must be doubtful — this 
plan should be persisted in until fever is subdued, then the course 
may be changed as in any other case, to a more generous diet, or 
invigorating regimen. If it run on to suppuration, it must be treated 
throughout its consequences, as any other abscess should be. 

24.^" The third indication must be fulfilled by the proper exhibition 
of opium, in its various forms. 

25. The fourth must be complied with, by the judicious adminis- 
tration of tonics ; as bark, sulphate of quinine, &c, &c, and by 
the daily use of the cold bath, where there are no contra-indications 
to render its use improper. 

26. I believe I am justified in saying, that women may very effec- 
tually recover, when the symphyses have suffered from mere relax- 
ation of their ligaments; but I fear we have but little reason to hope 
for an effectual cure, when the bones have been denuded of their 
cartilages, though the situation of the woman, by proper treatment, 
may be made comparatively comfortable. 

As the derangements either of separation, or of relaxation, of 
the pelvic symphyses are of very rare occurrence, I hope I shall be 
excused, for giving at length the cases communicated by Dr. A. J. 
Nicholson, in Vol. iv. p. 452, of the Transactions of the Association 
of Fellows and Licentiates of the King and Queen's College of 
Physicians, in Ireland. 

28. Dr. N. says, " It appears from the extensive observations of 
the most eminent accoucheurs in Paris, Vienna, and Dublin, that 
this disease is of rare occurrence. In the following case, the wo- 
man, after a natural delivery, did well to the fourth day, when she 
complained of an inability of moving her limbs. 

29. "On making inquiry, she informed me, that while at the fire 
she felt sick, and fell ofF the low seat on which she was sitting. 
The nurse tender had left her, and when she returned she found her 
fainting on the floor. When she recovered she was quite unable to 
afford herself any assistance. 

30. " In the course of the fifth day she was seized with frequent 
rigours, so violent as to shake the entire bed; and she complained 
of excruciating pain at the end of the os pubis, and along the course 
of the left thigh. The fainting and rigours returned to such an ex- 
cess, that I found it necessary to remain with her. Wine and other 
stimulants were given, which soon alleviated these distressing symp- 
toms. Her stomach, however, was at times much disturbed; and 
she was tormented with noise in her ears, and constant sneezing, 
which greatly aggravated the pain at the pelvis. 9 

31. "To relieve these unpleasant sensations, she took the black 
drop in large doses, which agreed extremely well with her. I at 
first tried opium, but it caused very unpleasant sensations when she 
closed her eyes, and kept her in a constant state of terror. 



24 OF THE SEPARATION OF THE BONES OF THE PELVIS. 

32. " On putting the finger over the symphysis, at its edge, cre- 
pitation was distinctly perceived ; a tumour was also observed on 
each side of the sacrum, on examining it particularly; the tumour 
was hard and circumscribed ; and about the size of a hazelnut. 

33. " Whenever she was moved, the pain was so agonizing, that 
she said they must be tearing her asunder. I communicated to the 
family my opinion, that the ossa pubis had separated,- and requested 
a consultation. In the mean time, I ordered her to be kept in a state 
of rest, and applied a firm broad bandage around the pelvis, from 
which she experienced the greatest relief, and found herself more 
comfortable than any time since her confinement. A solution of 
muriate of ammonia was applied to the tumours on the sacrum : they 
did not cause any considerable inconvenience, and were soon re- 
moved. 

34. " For nearly six weeks she remained perfectly well in her 
health, and easy in her bed, except when she attempted to move or 
turn on either side, on which occasion she always suffered the most 
violent pain. She could stretch her feet downwards, but could not 
draw them up again ; she found relief from leaning forwards, and 
placing her elbows on her knees ;• and when that position became 
irksome, she returned to her usual one on her back, when she always 
felt easy. About this time she menstruated, and though much benefit 
was expected from this circumstance, yet no alteration took place 
in her complaint. 

35. " A gentleman of considerable experience in midwifery, (Dr. 
Beatty,) saw her in about ten weeks from her confinement ; and, 
after a very careful examination, we found the internal parts in their 
natural situation, and free from ^disease. The perineum was not 
lacerated, nor was ihere the least appearance of injury about the 
external parts ; but on considering the seat of the pain, and the ina- 
bility of moving her limbs, there could be no doubt that the sym- 
physis of the ossa pubis had separated. The broad bandage was 
continued, with cold applications to the seat of the pain. A ban- 
dage, to keep the knees together, was also suggested by Dr. Beatty, 
and adopted. 

36. " In the course of conversation, after it continued for five 
months, the circumstance was related to a medical friend, who 
stated that he had a case somewhat similar, though more aggra- 
vated, a few years before. 

37. " In that instance it appeared that for several days before 
labour came on, she suffered much from pain and weakness in her 
back, and a total inability of moving herself, which caused her 
labour to be unusually severe, as she was unable to render herself 
any assistance. A crackling noise could be distinctly heard at 
several yard's distance, and not only were the pelvis and sacrum 
separated, but the disease seemed to have extended to the functions 
of all thebones of the pelvis. 

38. " Many medical men of eminence were consulted, and a 



OF THE SEPARATION OF THE BOXES OF THE PELVIS. 25 

variety of medicines were exhibited. Bark, wine, muriate of lime, 
carbonate of iron, tincture of iron, and every other remedy that could 
be thought of. At the end of seven months no improvement what- 
ever had taken place, and her situation being truly deplorable, he 
determined on using the shower-bath, the good effects of which were 
soon apparent ; for in a few weeks she was able to walk on crutches 
about the room, and in two months to go up stairs, which, to a person 
so affected, was an operation of no little difficulty. In three months 
she was fully restored to the use of her limbs, and has had a living 
child after a tedious but natural birth. 

39. " I immediately communicated the result of this case to my 
patient, who agreed to do willingly whatever I proposed. A partial 
shower-bath was contrived : and before the expiration of a month, 
not only great relief from pain, but much benefit was experienced; for 
she was once more able to pull on her stockings, and draw up her 
feet. 

40. " About two months after, she expressed a great inclination to 
try to walk, which I have often since regretted was not agreed to. 
She continued, however, free from pain, and in good health until 
December, (just twelve months from her confinement,) when, contrary 
to my wish and opinion, she was moved to her husband's house, as 
she had been confined at her father's. 

41. "She was put into a chaise, but whether from the motion of 
the carriage, or the confinement which she was obliged to be in, 
during two hours, I cannot say, but all the unpleasant symptoms 
returned, accompanied with great pain and the crackling of the 
pubis. 

42. "At this period I gave up my attendance, as I did not approve 
of the proceeding. She was put under the care of another practi- 
tioner, who, I understand, employed counter-extension to keep, as 
he termed it, £ the opposite sides of the pelvis in apposition.' This 
was contrived by keeping her upper and lower extremities fastened 
to the bed-post ; but it caused such pain, that she refused to endure 
it any longer : and matters having become much w T orse, I was requested 
to renew my attendance. I found her quite resigned to her situation, 
but without any hopes of recovery, to which she had so patiently 
looked forward. I persuaded her to return to the constant use of 
the shower-bath and belt, both of which had been much neglected. 

43. "I visited her at Easter, and staid with her two days; and was 
satisfied, from close observation, that she was in a fair way of recovery. 
She was playing with her child on the bed, and she turned herself in 
various directions without making any complaint: and her sister, 
who slept with her, told me that she had often turned on her side in 
her sleep, without experiencing any bad effect the next morning. I 
contrived a little carriage for her, in which she could lie lengthwise, 
and which was easily wheeled about the garden. The delightful 
sensation she experienced on once more breathing the fresh air, after 
being confined nearly eighteen months, may be readily conceived. 



26 OF DEFORMITY OF THE PELVIS. 

A pair of crutches was procured, and directions given, if she should 
have any inclination to stand or walk, to allow her to make a trial. 

44. " I had a letter from her about a month ago, in which she gave 
me the pleasing intelligence that she had either walked or shuffled 
half across the room, and felt no pain from the exertion; and every 
subsequent account confirms the pleasing prospect of her recovery." 

Sect. VI. — Of Deformity of the Pelvis. 

45. Every departure from the healthy dimensions of a pelvis, either 
by excess or diminution, is considered a deformity — I shall, therefore, 
first state the admeasurements of the different portions of this cavity, 
as generally agreed upon by writers, before I proceed to the consi- 
deration of such alterations as may justly be considered deformities. 

46. The diameter which runs from the superior part of the sym- 
physis of the pubes to the projection of the sacrum, in a well formed 
pelvis, is rather more than four inches ; while the one running from 
side to side, a little exceeds five inches ; and the one traversing the 
pelvis diagonally, from behind one of the acetabula to the union of 
the os innominatum with the sacrum, is nearly the same. The first 
of these is called the antero-posterior diameter, or small diameter of 
the superior strait ; the second, the transversal, or great diameter ; and 
the third, the oblique, which is also properly considered the great 
diameter. At the inferior part of the pelvis, or the lower strait, the 
measurements are nearly the same, but reversed — that is, the great 
diameter of this strait runs from the inferior edge of the symphysis 
pubis, to the point of the coccyx, allowing for the regressive power of 
this bone, and is usually rather more than four inches. The small 
diameter of the lower strait, is from the tuber of one ischium to that 
of the other ; and is about four inches. From this it will be seen, 
that the great diameter of the lower strait traverses the great diameter 
of the superior strait at right angles — this should be constantly borne 
in mind. 

47. It must also be mentioned, that not only the diameters of the 
superior and inferior straits do not coincide, but that their axes are 
also very different, owing principally to the curvature of the lumbar 
vertebrae, the promontory of the sacrum, and the retiring of this bone 
very considerably backwards. 

48. The deviations from the standard measurement are so numerous, 
that it would be almost impossible to enumerate them, \vere it even 
useful; I shall not therefore, descend to such detail, as it would 
fatigue the memory, without benefiting the understanding. I shall 
content myself with pointing out only such variations as may be prac- 
tically useful ; or such as would require a difference in the mode of 
terminating the labour. 

49. Deformities of the pelvis consist, first, in an excess of size in 
the diameters of this cavity ; and, secondly, in a defect of them. The 
first presents scarcely any obstacle that is not surmountable by common 



OF DEFORMITY OF THE PELVIS. 27 

means ; as a precipitation of the uterus within the pelvis during gesta- 
tion is the chief eviJ, occasioning some inconvenience or embarras- 
ment to the flow of urine, the alvine discharges, and the locomotion 
of the woman ; during parturition, a too rapid labour, threatening the 
escape of the uterus with its contents, from the os externum ; and 
after the birth of the child, giving rise to a profuse and alarming he- 
morrhage, by the uterus being too suddenly emptied, by the hasty 
expulsion of its contents. 

50. The first of these inconveniences may be remedied by the ap- 
plication of a proper-sized pessary — the second may be in a great 
measure prevented by a judicious management of the case during 
labour: 1. By forbidding the woman to bear down during pain. 
2. By opposing the too rapid escape of the child, by pressing firmly 
against it with the fingers within the vagina, so as in some measure to 
counteract the influence of the pains, if the uterus be but in part di- 
lated ; and if fully dilated, by making a firm pressure against the perineum 
with the extended hand, so as to allow of the more gradual passage 
of the head. The third may be at least very much diminished by 
brisk frictions upon the abdomen, immediately over the uterus ; by a 
proper management of the placenta; and by the immediate exhibition 
of twenty grains of the powdered secale cornutum. 

51. That departure from the standard pelvis, (46,) which consists in 
a diminution of its principal diameters, is much more common, and 
much more serious in its consequences, than the one I have just con- 
sidered : for the difficulties are increased in proportion almost to the 
deviation from the healthy proportions just enumerated. 

o2. The most common cause of the distortions of the pelvis ; is 
rachitis in infancy and childhood ; and of malacosteon, in the more 
advanced periods of life. The former of these diseases hinders the 
proper consolidation of the bones ; and thus exposes them to the in- 
fluence of any pressure that they may be subject to, during its con- 
tinuance. This being the case, it will be very readily understood 
how a pelvis shall receive injury while labouring under this disease ; 
for on it is exerted the weight of the body from above, when the child 
is either sitting or standing: this carries the projection of the sacrum 
still more forward ; while the acetabula serve as fulcra to the lower 
extremities, when it is standing on its feet, and thus obliges the yield- 
bones to retire towards the sacrum : hence, in some extreme cases, 
approximation of these parts is such, as to leave but a very few 
lines of opening between them. 

It rarely happens that ever}- part of the pelvis is equally affect- 
ed by rickets ; and when it is not, the consequences will be different, 
both in degree and in location. Sometimes, but one side will have 
suffered by this extraordinary disease ; while the opposite shall be 
free from all complaint, and preserve its original healthy conformation 
— at others, it is still more partial, and only affects one small part of 
this cavity — while again, every portion of it seems to participate in 
the derangement ; then the consequences become most lamentably se- 



28 OF DEFORMITY OF THE PELVIS. 

rious. The upper strait is generally the most injured, and that almost 
constantly in the direction of its antero- posterior diameter ; leaving 
the transversal one as large, and sometimes even larger, than usual ; 
and the inferior strait sometimes without blemish. 

54. When the inferior strait is defective, it is usually in the direc- 
tion of its small diameter ; this is affected by the approximation of 
the tubers of the ischia. It may also be faulty in several other ways 
— 1. By the spine or spines of the ilia looking too much inward. 
2. By the symphysis pubis being too salient. 3. By the symphysis 
being too long. 4. By the processes of the ossa pubis running down 
in a too perpendicular direction. The healthy depth and form of the 
pelvis may be injured in various ways — I. By the sacrum being too 
strait. 2. By its having too great a curvature. 3. By the coccyx 
looking too much upwards. 4. By this bone losing its regressive mo- 
tion, by being anchylosed with the sacrum. 

55. But as every degree of deviation does not render labour im- 
practicable by the natural agents of delivery at full time, it will be 
well to fix the boundary, which the practitioners of Europe of the 
greatest experience have affixed for it. It seems to be pretty gene- 
rally conceded, that a labour cannot be successfully terminated, when 
there is less than three inches in the antero-posterior diameter of the 
superior strait. When a pelvis has three inches, or even three inches 
and a half in this diameter, the labour is rendered, for the most part, 
tedious, painful, and uncertain.* We hear of some remarkable cases, 
however, of children being born alive, when there have been but two 
inches and three-quarters from the pubes to the sacrum ; but these 
must constantly be regarded as exceptions to the general rule ; and 
require, that it may take place, an unusual suppleness in the bones of 
the cranium. f See Baudeloque, &c. 

56. I have appealed above to the experience of the European ac- 
coucheurs for the datum, that labour at full time is impracticable, 
when there is less than three inches in the small diameter of the su- 
perior strait. — I do this, because I believe that the united experience 
of all the American practitioners, would not have led to a correct 
conclusion on the subject ; as the occurrence of deformity of pelvis 
in this country is so very rare, as never to have been even encountered 
by some practitioners of pretty extensive experience. And as far as 
regards my own experience I must declare that I have not met with 
extreme deformity in American women three times in my life ; and 
when it has occurred to such an extent as to render labour impracti- 

* This can be easily understood, when it is recollected, that the transversal diame- 
ter of the child's head (82) very rarely can be reduced to less than three inches, with 
impunity; consequently, when this diameter measures more than three inches, or the 
antero-posterior diameter of the pelvis measures rather less, the labour must always be 
protracted, and dangerous to the child. 

t The French measure is rather more than the English; that is, the French inch is 
thirteen lines English. A line is the twelfth of an inch ; consequently, two inches 
three-quarters French, make three inches within a fraction, English. 



OF DEFORMITY OF THE PELVIS. 29 

cable by the natural powers, it has uniformly been with European 
women.* 

57. Rickets, among the children in this country, is so rare, that 
practitioners of considerable experience have declared to me, they 
have not witnessed a case, nor is this much to be wondered at ; since 
the remote causes of this disease are rarely present. Our population, 
even in our largest cities, is not crowded like those in many parts of 
Europe. That we have many poor, must be confessed ; but even 
these poor enjoy comparatively a purity of air, and a wholesomeness 
of diet, unknown to many of the same class in Great Britain, or in 
many parts of the continent of Europe. Very little, indeed, of our 
population live under ground, or are very thickly crowded together. 
They are not compacted in confined manufactories, nor exposed to 
many of their deleterious operations. It is a rare occurrence if even 
our beggars do not regale themselves daily, on more or less of animal 
food ; and certainly the population with us, which would correspond 
with the common manufacturers of Europe, are for the most part, suf- 
ficiently, nay, oftentimes, abundantly supplied with it ; hence our 
general exemption from rickets, and of course our freedom from its 
consequences. 

58. I have said above, (53,) that when a pelvis is injured in its 
proper proportions, it is almost always in the small diameter of the 
superior strait. Dr. Denman, however, declares it to be always in 
this diameter, when this straight is faulty, and never in the direction 
of the great one ; but in this I must differ from this experienced and 
respectable practitioner ; for it was my chance to meet with two in- 
stances of this kind in practice, as well as to be in possession of a 
natural pelvis, where the diameters at the upper strait are reversed. 
Besides, Baudelocque admits the fact, though he says it is very rare. 

59. One of the cases alluded to above, occurred to me within a 
few years, and as it is of some interest from its rarity, I will relate it. 
On the 18th of March, 1824, at 9 o'clock, A. M., I was called to 
Mrs. , in labour with her seventh child. She had been com- 
plaining, during the whole of the previous night, but the pains did 
not become efficient, in her estimation, until about the time I was 
sent for — at this time the pains were very slow, but pretty forcing. 
Lpon examining per vaginam, the os uteri was found but little di- 
lated, much tumefied, but not rigid. As there was no immediate ne- 
cessity for my presence, I took my leave, desiring the nurse to send 
immediately, should any change take place before my intended return. 
I saw her several times during the day, although no alteration had 
taken place, in either the force or frequency of her pains. At about 
10 o'clock, P. M. of the same day, I was again summoned, in conse- 
quence, as the nurse said, of her having had several pains nearer each 
other, and " smarter." Upon a second examination every thing was 

* In this I am happy to find myself supported by the testimony of Professor 
James, in a note affixed to his edition of Burns' Midwifery. Note k, p. 35. 

4 



30 OF DEFORMITY OF THE PELVIS. 

found pretty much as it was in the morning — in the course of two 
hours more the pains became more frequent[and urgent ; and the os uteri 
was found more dilated, but still tumid ; the head of the child still 
very high up, indeed, was scarcely to be felt. Two hours more were 
unprofitably employed, in the hope of the advancement of the head : 
thinking it probable that this did not take place, because the mem- 
branes were entire, and apparently more than usually rigid, I ruptured 
them and gave issue to a very moderate quantity of liquor amnii — the 
head did not yet descend, as was hoped, though more within reach ; 
and as the pains were now rather brisker, without manifestly ad- 
vancing it, I was induced to examine into the cause of the delay more 
particularly. Upon a careful search being made, as regarded the pel- 
vis, it was found that the point of the coccyx looked very much up 
into the pelvis ; and the projection of the sacrum could not be felt 
by the finger ; it seemed to retire unusually far posteriorly ; the sides 
of the pelvis could be easily traced at the upper strait : and on the 
anterior portion of the pelvis, immediately behind the symphysis of 
thepubes, two fingers could be introduced with their breadth between 
it and the child's head. The head of the child was found to occupy 
completely the transversal diameter of the superior strait — it now oc- 
curred to me, that this was an instance of deformity, in which the 
transverse diameter was injured, and which of course produced an 
increase in the antero-posterior diameter ; and that the head being 
placed transversely above, could not enter the strait in that direction. 
With this in view, I introduced my hand, and placed the head in such 
a manner as to make the posterior fontanelle answer to the pubes, and 
the anterior to the sacrum, and then withdrew it. Twenty grains of 
the ergot were now given, with a hope that the pains would follow 
each other more quickly, as well as be rendered more powerful — but 
the first pain after this, made the head descend to the lower strait, and 
four more delivered it — there was a little delay with the shoulders, 
but they followed the second or third pain. 

60. This lady, though the mother of six children previously, had 
never had an untoward accident from this peculiar conformation — but 
her labours she represented as having always been very tedious and 
severe — four hours of extremely hard pains was the shortest period she 
had ever known, after she had found herself what she called " to be in 
earnest."* 

51. During the existence of rickets, the child is constantly exposed 
to doing itself mischief by almost any position it may take ; if it be 
placed on its feet, two powers are acting to this end ; the weight of 
the body upon the sacrum from above, and the pressure of the heads 
of the thigh bones upon the acetabula from below ; producing either 
moderate or extreme deformity, as the disease may be more or less 
severe, or as the patient may be more or less disposed to exert its lower 

* There is a species of deformity which we have never met with, namely, "the fun- 
nel shaped." Dr. Rigby notices it in his valuable System of Midwifery, which is the 
only notice I have seen of it. It must ereate in labour great embarrassment. 



OF DEFORMITY OF THE PELVIS. 31 

limbs. In sitting, the weight of the body is sustained by the tubers of 
the ischia, and the point of the sacrum ; hence the latter may become 
too much curved, and the former be made to injure the length of the 
processes of these bones, as well as those of the pubes, and thus do 
mischief to the arch formed by these bones. If carried in the arms 
too constantly, the whole of the lateral portions of the pelvis may 
become injured by the pressure of the nurse's arms. 

62. To guard against these evils, Baudelocque (System, page 61, 
par. 92.) suggests a very important practical direction ; which is, to 
keep the patient as much as possible in a horizontal posture, and to 
permit him to exercise his little limbs freely by sprawling upon a bed 
or mattress. 

63. Injuries arising from malacosteon are more rare, but not less 
grievous than those from rickets — of the former I have never wit- 
nessed an instance. Mr. Burns,* says the women of manufacturing 
towns are particularly obnoxious to it. It begins very soon after de- 
livery, and very frequently during pregnancy ; and is comparatively 
rare in women who do not bear children, and is always hurried in its 
progress by gestation. Hitherto, no remedy has been discovered 
capable of arresting its progress, or preventing its occurrence. He 
recommends to such women as are afflicted with it, to live "absque 
rnarito." 

64. The pelvis may also be injured by exostoses and tumours, 
which may give rise to either very difficult, or even impracticable 
labour — of the former I have witnessed but one case, and that oc- 
casioned a rupture of the uterus ;f of the latter I have never had the 
misfortune to meet with a single instance. They are occasioned in 
some instances by enlargement of the ovaria or glands ; or they may 
consist of some adventitious substance within the pelvic cavity. They 
are said to be often moveable when of the ovarian kind ; and fixed 
generally when of the other. They are found to have but cellular 
attachments; and are of easy removal, by making an incision through 
the vagina, and evacuating the contents of the tumour. There is a 
kind, however, which either adheres by a pedicle, or has a broad 
base : these can only be removed by deep cutting, and are, for the 
most part, cartilaginous. 

65. Mr. Burns has laid down the following practical rules for the 
government of those, whose ill luck, may put them in possession of 
such cases — 1st. u Whenever the tumour is moveable, it should be 
pushed above the brim of the pelvis at the commencement of labour, 
and prevented from again descending before the child." 

66. 2d. " That we should never permit the labour to be long pro- 
tracted, but early to resort to the means of relief." 

67. 3d. " As it is impossible to decide with certainty on the nature 
of the contents of many of these tumours, we should in all cases, 

* Principles of Midwifery. James' edition, p. 34. 

t See Essays on Subjects connected with Midwifery, by the author, p. 75. 



32 OF DEFORMITY OF THE PELVIS. 

where we cannot push them up, try the effects of puncturing with a 
trocar. If the contents be fluid, we evacuate them more or less com- 
pletely; if solid, we find the cannula, when withdrawn, empty or filled 
with clotted blood ; if fatty, or cheesy, the end of the tube retains a 
portion, and we are thus informed of its nature." 

68. 4th. " When the size of the tumour cannot be sufficiently or 
considerably diminished by tapping, I am inclined, from the unfavour- 
able result of cases where the perforator has been used, and from the 
severe and long-continued efforts which have been required to accom- 
plish delivery, to recommend the extirpation of the tumour, rather than 
the use of the crotchet. There may, however, be situations where 
the incision ought to be made in the vagina ; but these are rare. But 
extirpation cannot in any mode be proposed, if firm cohesions have 
been contracted between the tumours and vagina or rectum.. 

69. 5th. "If the extensive connexions, extent, or nature of the tu- 
mour, or danger from hemorrhage, prohibit extirpation, or the patient 
will not submit to it, and it has been early ascertained that tapping is 
ineffectual, I deem it an imperative duty to urge the perforation of the 
head, or extraction of the child, as soon as the circumstances of the 
case will permit." 

70. 6th. " Much and justly as the Caesarean operation is dreaded, 
it may with great propriety be made a question, whether, in extreme 
cases, that would not be less painful, and less hazardous to the mo- 
ther, than those truly appalling sufferings which are sometimes inflicted 
by the practitioner for a great length of time, when the crotchet is 
employed; whilst it would save the child, if alive at the time of inter- 
ference. I am aware that it may be objected to this opinion, that in 
those cases, the tumour being softer than bone, the same injury will 
not be sustained as if the soft parts had been pressed with equal force 
and for the same time, against the bones of a contracted pelvis, and 
that in point of fact, recovery has taken place, though the strength of 
the two able practitioners was exerted and exhausted during several 
hours, but such an instance cannot establish the safety of the practice." 

71. 7th. "It is scarcely necessary for me to add that there may be 
different degrees of encroachment, which admit of the safe and suc- 
cessful application of the forceps, and of this matter we judge by the 
size of the tumour, and the capacity of the pelvis."* 

72. This subject is highly interesting to the accoucheur ; and I 
would refer, for farther information, to the chapter from which the 
above is derived ; and where a number of important references are 
made, to various authorities, for cases illustrative of the views of the 
gentlemen into whose hands they fell. It is a matter of much moment, 
in the event of meeting with such a case, that we should be well ac- 
quainted with the best mode of treating it ; for however rare such 
instances may be in this country, they certainly may occur ; and to 

* See Davis' Elements of Operative Midwifery v page 90, in- which this subject is 
treated at some length, and some interesting views^ and cases v are furnished. 



OF DEFORMITY OF THE PELVIS. 33 

be ignorant of the resources of the art upon such an occasion, would 
be a reprehensible want of information. In addition to the case re- 
lated by Mr. Burns, we subjoin the following interesting as well as 
important operation, from the Med. and Phys. Journ. Vol. 13th, p. 

73. "An account of two cases of tumours in the pelvis, growing 
out of the sacro-sciatic ligament, one of which terminated fatally, and 
the other was cured by extracting the tumour through an incision 
made into the cavity of the pelvis, through the peritoneum, by P. P. 
Drew, M. D., Fermoy, county of Cork. 

74. " This is a very important paper, insomuch as it authorizes an 
operation, which, but for the event, some people might have called rash. 
In the first case, the boldness of the undertaking deterred the surgeons 
from attempting it, apprehending that the tumour might be connected 
with the larger blood vessels in the inside of the pelvis. The in- 
crease of the tumour at last produced a total interruption to the pas- 
sages of the urethra and rectum; and during the absence of Dr. Drew, 
the patient died convulsed. 

75 "On making a free opening into the pelvis after death, the 
tumour was easily turned out, having no communicating blood ves- 
sels, and only a slight attachment to the surrounding parts, excepting 
at its neck, which seemed to grow out of the sacro-sciatic ligament. 
Its texture was gristly, and the body of the tumour was a fat gristly 
substance. This view of the parts after death, suggested to the ope- 
rator a question, whether the tumour might not with safety have been 
removed during life, by making an incision on one side of the peri- 
neum and anus, backwards, towards the os coccygis ? 

76. "About six months afterwards, the second case occurred. 
The first time Mr. Drew saw the woman was the second day of her 
labour, in consultation with three other medical gentlemen, whose 
signatures he has thought it right to affix. The recollection of the 
former case, suggested the only remedy in the present. Either the 
Caesarean operation, or the extraction of the tumour was absolutely 
necessary. Besides the well-known danger of the former, even 
should it succeed, the diseased part would remain. Mr. Drew, there- 
fore, undertook the operation of extracting the tumour by the peri- 
neum, and succeeded. The woman was soon after delivered of a 
living child, and when the case was transmitted, both were doing 
well. 

77. " On the success of this important operation, which does so 
much honour to the operator and to surgery, it is unnecessary to make 
any remarks ; but we cannot dismiss the article without wishing gen- 
tlemen who are most in the habit of deciding upon such cases, to 
consider whether some of those tumours which arise from the ovaria, 
and are confined to the pelvis, might not with safety be extracted in 
this manner. We mean not to propose a hazardous operation, where 
the patient feels no other inconvenience than her increased bulk ; but 
where the offices of the neighbouring parts are so much interrupted as 

4* 



34 THE EXAMINATION OF THE PELVIS. 

to render life no longer desirable, such a proposal might be submitted 
to the patient." 

Sect. VII. — Examination of the Pelvis. 

78. A variety of means have been proposed for measuring the 
pelvis, in order to ascertain the diameters of the various parts con- 
cerned in the passage of the child ; much ingenuity has been expended 
with a view to, and hope of accuracy ; but we have reason to fear that 
none hitherto projected has attained this end. The pelvimeter of 
Monsieur Coutouly* is liable to serious objections ; especially as it 
effects to ascertain the state of the pelvis, by developing itself within 
its cavity ; for, 1st. It is very difficult, as well as uncertain, in its 
application ; 2d. It cannot be applied but to the upper strait, not 
being calculated for the measurement of the inferior strait ; 3d. Its 
results are not by any means certain ; as they have been known to vary 
several lines from the true measurement ; 4th. It always excites pain, 
however skilfully applied, and excites action in the parts, so as to 
render the result very doubtful ; 5th. It cannot be applied to young 
girls to whom the knowledge of the state of their pelves may be high- 
ly important. We must not, therefore, permit ourselves to be se- 
duced by its ingenuity and its apparent simplicity. 

79. Baudelocque relies with much confidence upon the caliper ; 
and declares, that its results are so uniform, as scarcely to present 
a line of difference when taken before the body is opened, and what 
is found after it has been subjected to the knife. I may add, my 
own few experiments upon the dried pelvis are in entire conformity 
with the assertions of this most valuable author. The mode of apply- 
ing it is extremely simple : one of the lenticular extremities of the 
calipers is applied to the centre of the mons veneris, the other to the 
centre of the depression of the base of the sacrum, or a little under 
the spine of the last lumbar vertebra : having ascertained exactly the 
distance between these extremities, which is accurately done by means 
of the graduated scale attached to the instrument, you deduct from it 
three inches for the base of the sacrum, and the anterior extremities 
of the ossa pubis, if the woman be thin ; and a little more should the 
woman be fat. If this result be so uniformly accurate as Baude- 
locque declares, w T e need not want a more exact mode of ascertaining 
the opening of. the upper strait. One fear, however, presents itself to 
us, that considerable error may be committed, if the extremities of 
the instrument be not accurately placed upon the points indicated ; 
for I found upon the prepared pelvis, that a half inch higher or lower 
than the spine of the last lumbar vertebra, would affect the result: 
now, on the living subject, especially if that subject be fat, it is not 

* Madame Boivin has also invented an instrument which she calls "intropel 
vimetere. Its principles are much the same as Coutouly's, though it differs consider- 
ably from it. It consists of two branches, which are introduced separately — one into 
the rectum, and the other into the vagina; and, it is said, may be employed in the 
▼irgin as well as in the pregnant woman. I have never met with a particular de~ 
scription of it. 



THE EXAMINATION OF THE PELVIS. 35 

very easy to determine the precise spot. Again, I have seen dried 
pelves, so peculiarly distorted, as to have the superior portions of the 
ossa pubes pressed almost close together ; by which means, the sym- 
physis pubis is thrown as much in advance, as these bones lost in their 
circular direction. In such cases the whole of the anterior superior 
portion of the pelvis, not concerned in the extension of the symphysis 
pubis, is made almost to touch the posterior internal portion of the 
pelvis ; consequently the distance between the symphysis pubis, and 
the projection of the sacrum is greater than natural ; while the supe- 
rior opening of the pelvis, may not exceed half an inch ; yet mea- 
suring by the calipers, it would give several inches in the anteropos- 
terior diameter. 

80. We may also, with considerable accuracy, determine the 
antero-posterior diameter, by introducing the finger into the vagina, 
and placing its extremity against the most projecting part of the base 
of the sacrum, and allowing the radial edge of it to press against the 
arch of the pubes ; marking the part of the finger which is immediately 
below the symphysis, by the nail of the finger of the other hand; as- 
certain the distance between it, and its extremity, and it will pretty 
faithfully give the width of the small diameter of the upper strait ; it 
must, however, be recollected, that a little allowance must be made 
for the oblique manner in which the finger descends from the sacrum 
to the symphysis of the pubes. Or we may ascertain with great ac- 
curacy in time of labour, the degree of opening at the superior strait, 
by introducing the hand into the vagina, and placing some fingers 
edgewise between the posterior part of the symphysis pubis, and the 
projection of the sacrum — the width of the fingers so employed, can 
easily be measured after the hand is withdrawn from the vagina. 
Velpeau* declares, that with the finger we may estimate every species 
of deformity of the pelvis, wherever it may be situated, or of whatever 
nature it may be. 

81. We may very nearly assure ourselves of the extent of the small 
diameter of the inferior strait, by placing the woman in such a situa- 
tion as will give extreme flexion to the thighs; that is, make her 
squat : the tubers of the ischia can very readily be felt, if the woman 
be not very fat; ascertain the space between the finger placed on each 
tuber, and it will give you the width of the lower strait pretty accu- 
rately, especially, if you deduct two or three lines for the thickness of 
the bones. 

* De l'Art. des Accouchemens, Tom. 1 ; p. 51. 



36 



CHAPTER II. 

OF THE CHILD'S HEAD. 

82. It is absolutely necessary for the well understanding of the 
mechanism of labour, that the various dimensions of the child's head 
be accurately known, as a proper relation must exist between it and 
the cavity through which it is to pass, that labour may not be ob- 
structed. We are to consider four principal diameters, as belonging 
to the head, viz., 1st, The oblique ; this diameter runs from the sym- 
physis of the chin to the posterior and superior extremities of the pa- 
rietal bones, or posterior extremity of the sagittal suture ; 2. The 
longitudinal diameter : this runs from the centre of the forehead to the 
top of the lambdoidal suture ; 3d. The perpendicular, or the diameter 
subtending from the summit of the head, to the base of the cranium ; 
4th. The transversal, or the diameter which extends from one parietal 
protuberance to the other. 

83. The first of these diameters will be constantly called the large 
diameter of the child's head : the second will be called the longitu- 
dinal diameter; and the third the perpendicular diameter; while the 
fourth will constantly be considered as the small diameter. 

84. These diameters are very often altered from their natural mea- 
surement during the progress of labour, by the pressure the head sus- 
tains in its'passage through the pelvis ; but all cannot be diminished or 
increased at the same time. If the head be so strongly pressed so as 
to diminish one diameter, it is sure to be increased in another ; for 
instance, if the transverse diameter be diminished, the oblique will as 
certainly be augmented ; and when the head becomes much elongated, 
as it sometimes does, it is almost always in the direction of this last 
diameter. 

86. The extent to which this elongation in one direction, and di- 
minution in another, can be carried, must vary considerably in indi- 
vidual cases ; owing to the degree of pliability of the bones ; the ex- 
tent of separation of the sutures, and the size of the fontanelles ; the 
transverse diameter may be diminished, sometimes six or eight lines, 
while the same length may be gained by the oblique. This compres- 
sion, however, must necessarily have its limit ; and this should con- 
stantly be borne in mind ; especially in the application of the forceps. 
For, if carried too far, there is a risk of fracturing the bones, wounding 
or too strongly pressing the brain, or producing extravasation within 
its substance, or in the cavity of the cranium. Owing to the different 
degrees of hardness to which the bones of the foetal head may arrive 
while in utero, there must necessarily be a difference in the risk the 
child runs from compression ; one head suffering with impunity a loss 
of six or eight lines in one of its diameters, while half this might be 



fatal to another. The perpendicular diameter suffers in general but 
little by the efforts of labour, however long-continued, or however 
strongly the head may be urged. The longitudinal diameter, when 
the head is well situated, is but little liable to compression, or alteration ; 
but when it does, it increases the head in the direction of the trans- 
verse diameter. 

86. The child's head, like that of the adult, is composed of a num- 
ber of bony pieces ; but they are not united in the same manner; in 
the child's head the principal bones, (and these as regards our subject, 
are all we have to consider,) are tied together by a firm ligamentous 
substance ; and the lines formed by this union are called sutures ; these 
are three in number. 1st. The sagittal suture, or the line of union 
from the anterior portion of the occipital bone to the root of the nose ; 
passing between, and connecting the parietalia, and dividing, yet 
connecting the frontal bone, into two equal portions. 2d. The coro- 
nal suture, or the line which connects the anterior portions of the 
parietalia, and the posterior and semicircular portions of the frontal 
bone ; and passes from near the superior portion of one ear to that of 
the other. 3d. The lambdoidal suture or the line serving to tie to- 
gether the posterior portions of the parietalia, and the anterior supe- 
rior portion of the occipital bone. 

87. From this arrangement, it will be seen, that the sagittal suture 
traverses the coronal suture at nearly right angles ; and at the points 
of decussation leaves an open space* or fontanelle. This is not al- 
ways of the same size, owing to the more or less perfect ossification 
of the bones — but we always remark in it the following circumstances, 
and which deserve to be noticed, as they serve to distinguish it from 
the one next to be mentioned — there are always four bony angles at 
this fontanelle; the edges of which are almost always tipped with car- 
tilage ; easily depressed and smooth ; and very often nay almost al- 
ways, a space of considerable size is left, which is soft, smooth, and 
yielding, and can be distinctly felt by the point of the finger; this is 
called the anterior fontanelle. The other fontanelle is formed by the 
termination of the sagittal, in the centre of the lambdoidal suture ; and 
has but three bony angles ; two by the posterior and superior point 
of the parietalia, and the central point, of the occipital bone. The 
union of these last named sutures does not leave the same degree of 
opening as the one we have just considered ; though sometimes 
it is considerable, but always much less than the anterior — for 
when the posterior is well marked, the anterior is constantly found 
to be larger. Besides the circumstance last mentioned, we fre- 
quently remark, that the edges of the bony angles forming the 
posterior fontanelle, are more completely ossified, and present to 
the finger, when pressed, a serrated edge ; and sometimes these 
little bony projections are so strongly marked, as to resemble 

* T have met with two instances in children of the same individual, of an interme- 
diate fontanelle — these, in both cases, were situated about midway from the anterior to 
the posterior fontanelle. 



38 of the child's head. 

small tooth-like processes; a character which the edges of the anterior 
fontanelle never possess ; and which serves very certainly to distin- 
guish it from the other. 

88. It sometimes happens, however, that the sagittal suture is con- 
tinued through the middle of the os occipitis to its base : in such case, 
four bony points are offered to the touch ; but their size and general 
character are so different from the anterior, as but very rarely to 
mislead. 

89. We would earnestly recommend the study of the fontanelles 
and sutures, to the beginner in the practice of midwifery: he should 
very early accustom himself to touch and distinguish them — it will 
lead him to a knowledge of the situation of the head when within the 
pelvis ; and constantly and certainly apprize him of any departure 
from its best position ; and thus enable him, at a proper time, to 
effect any change that may be necessary, with a view to render the 
labour safer, easier, and of more speedy termination. No man can 
render assistance with any certainty, where the head has departed 
from its proper route, who is incapable of distinguishing this aberra- 
tion by the touch: he whTeither not distinguish the faulty position, 
and thus condemn the poor woman to protracted and unnecessary 
suffering ; or he will blindly, and rashly attempt relief, at the hazard 
of the lives of mother and child. 

90. Many rely upon the position of the ear, for the knowledge of 
the situation of the head, but we seriously object to this uncertain 
test : 1st. Because the head may be so high in the pelvis, as to be 
out of the reach of the finger when it may be essential to determine 
its position, whereas the fontanelles can always be commanded ; 2d. 
The head may be so impacted in the pelvis, as to prevent the finger 
from passing to the ear ; 3d. And when this is felt, it may' give, from 
some peculiarity of situation, or the imperfection of the touch, a wrong 
impression of its position ; 4th. When the head is still enclosed within 
the uterus, the finger cannot always be made to pass sufficiently far 
under its edge to reach the ear, though the os uteri may be sufficiently 
dilated for all the purposes of delivery. 

91. It is important that the connexion of the head of the child with 
the trunk, should also be well understood ; otherwise the child may 
sustain much injury, if not death, from an ignorance of it — it must be 
constantly recollected, that the head cannot with safety execute a 
motion upon the neck beyond a quarter of a circle, when it is freed 
from the pelvis, and the body retained within that cavity ; nor can 
the cervical vertebrae more safely perform a greater sweep, when the 
head is detained, and the body is without. A want of attention to 
this fact, I have great reason to fear, has caused the death of more 
children than I would dare to mention ; especially when they have 
presented by the breech, feet, or knees, or when turning has been 
resorted to. I well recollect one instance of footling presentation, 
where the child was delivered to the head, and the midwife who had 
charge of the case, could not succeed in delivering it: I was sent for; 



OF THE GENITAL ORGANS. 39 

and was obliged to give two entire turns of the body, before the twist 
was removed from the neck ; I need not mention the fate of the child. 
Fewer errors of this kind are committed when the head presents; not 
because the cases are not similar, under equal circumstances; but 
because the shoulders are seldom long retained after the exit of the 
head; and, consequently, there is less temptation to employ ill-directed 
force. 



CHAPTER III. 

OF THE GENITAL ORGANS. 

92. Of the parts concerned in generation and delivery, some are 
detected without the use of the knife, while others are only brought 
into view by dissection ; hence they have been divided into external 
and internal. The external consist of the mons veneris, the labia, the 
clitoris, the nyrnpha?, the meatus urinarius, the hymen, the orifice of 
the vagina, the carunculse mytriformes, the fraenum labiorum or four- 
chette, and the fossa navicularis. The internal organs are the uterus, 
the Fallopian tubes, the ovaria, the ligaments, and the vagina. 

93. Immediately over the symphysis of the pubis, and part of the 
insertion of the recti muscles, we find a prominence, which in the 
adult is covered with hair — this is the mons veneris ; it consists of an 
accumulation of cellular, and adipose membrane — we know of no 
decided use of this part ; and more especially, for its being covered 
with hair. Apparently taking rise from this part, we find two bodies 
of similar appearance and texture, running parallel to each other, in a 
course downward and backward — these are the labia pudendi ; their 
external faces are protected with the common skin, and are studded, 
like the mons veneris, with capilli ; their internal surfaces are covered 
with a beautifully fine, and sensible membrane, of a florid colour in 
young subjects, but which is lost, as age advances : this surface is 
abundantly supplied with glands, that constantly secrete a fluid for 
the especial protection of these parts against adhesion. 

94. On separating the labia, several other parts are immediately 
brought into view. The clitoris presents itself, directly beneath the 
superior union, or, if you please, the origin, of these bodies. It con- 
sists of several parts ; namely, two crura, which have their origin in 
the ossa ischia, and running along the branches of the ossa pubis, 
unite upon the symphysis, and form the body of this organ ; these 
crura are connected by ligament to these bones, somewhat after the 
manner of the penis in males ; its external termination, from a sup- 
posed resemblance, has been called its g Ian s ; but it is without ure- 
thra, being imperforate ; a duplication of the internal membrane of the 



40 OF THE INTERNAL ORGANS. 

labia, forms its preputium. It has like the male organ, two corpora 
cavernosa, and an intermediate septum ; it has also the power of erec- 
tion, through the agency of two erector muscles, which arise from 
the ossa ischia, and are inserted into the corpora cavernosa. It is 
supposed, but without sufficient proof, to contribute to sensual gratifi- 
cation.* It is this part, when preternaturally enlarged, which has 
given rise to the various reports of hermaphrodites. 

95. It is furnished with blood vessels from several sources : both 
arteries and veins are branched from the hypogastrics and vassa pu- 
denda. Its nerves, which arise from the sacri, endow it with great 
sensibility. 

96. Depending, as it were, from the clitoris, are two similar bodies 
called the nymphse — they separate more widely as they proceed, and 
run downward towards the os externum ; they are very vascular ; they 
also possess, beside a common cellular structure, an erectile or 
spongy tissue, somewhat analogous to the corpus spongiosum of the 
male penis : and in virgins are, like the whole of the internal face of 
the vulva, of a bright red colour, and are supposed to augment vene- 
real gratification — they certainly are very distensible, and unques- 
tionably contribute by this property, to diminish the risk of lacera- 
tion from the passage of the child during labour.f 

97. In the centre of, and between the inferior extremities of the 
nymphaB, the orifice of the urethra is found; and though, strictly 
speaking, it does not belong to the organs of generation, yet it is of 
such importance in many cases connected with gestation and labour, 
as to render a familiar acquaintance with it absolutely necessary in 
the practice of midwifery. I shall have, upon another occasion, to 
revert to this part with more exactitude as regards location, &c. The 
canal or urethra, of which this is the outlet, is from one inch and a 
half to two inches in length, and processes from the urinary bladder : it 
is more capacious, and more distensible, than the male urethra : per- 
mitting, in some instances, calculi of considerable size to pass, with- 
out much inconvenience or distress; and if this tube be slit up to 
its origin, it will be found studded with numerous mucous lacuna?; 
two of which at its orifice are particularly large — in the unirapreg- 
nated state of the uterus, its direction is nearly horizontal. 

98. Below the orifice of the urethra, and almost immediately under 
the symphysis pubis, the orifice of the vagina or os externum is found 
— it may be said to occupy, in its undisturbed state, a considerable 
portion of the arch of the pubes, but its limits are very much increased 

* Velpeau seems to be of this opinion, but gives no proofs in support of it: be says, 
" The intimate structure of the clitoris is such, as to allow of an accumulation of 
blood in it during coition, so as to become swollen and erect; the fine membrane which 
covers it is very sensible, and hence has been looked upon as the principal seat of 
venereal pleasure." — Velpeau, Traits EUmenlaire de V Art des Accouchemens. Tom. i. 
p. 60. 

t Velpeau denies very dogmatically what is here asserted to be the supposed uses of 
the nymplire, (as first suggested, we believe, by Smellie,) but without giving the rea- 
sons for his objections. 



OF THE GENITAL ORGANS. 41 

during the passage of the head of the child at the end of labour; it 
then extends below the tubers of the ischia. It is surrounded by 
a sphincter, which arises from the sphincter ani ; and is accompa- 
nied by the plexus retiformis. This sphincter has various degrees 
of power ; owing either to original conformation, or the habit of exert- 
ing it, or both. A medical friend informed me, he had a patient 
who had such entire control over this constrictor, as to enable her 
to retain an injection per vaginam, as long as she pleased ; and lately 
I have met with a similar instance. 

99. In the virgin state, this orifice is almost always partially oc- 
cluded by a membranous expansion, called the hymen — this partition 
is situated immediately within the orifice of the vagina, and seems 
to spread itself over, and be the connecting medium of the caruncu- 
lae myrtiformes. It is almost constantly pierced by a hole, which 
gives issue to the menstruous secretion ; when it is not, it gives occa- 
sion to such an accumulation of this fluid as to produce great pain, 
and to require, for the most part, the interference of art. This mem- 
brane has been considered by many celebrated anatomists, as a crea- 
ture of the imagination ; but I am abundantly convinced by multi- 
plied observation, that it really exists; and in the museum of our 
Medical College, several beautiful specimens may be seen. Among 
the Jews, a discharge of blood, which was supposed to proceed from 
the rupture of this membrane in primo coitu, was considered as the 
test of virginity. 

100. The existence of the hymen, we have just said, has been 
doubted ; men of much learning and talent are enlisted on both sides 
of the question, and much difficulty would be experienced by the 
tyro in anatomy, whichever side of the question he would adopt. 
But if opportunity present itself for the investigation upon a proper 
subject, either dead or living, it will not fail to convince him of the 
existence of this membrane ; for our own experience declares it pal- 
pable ; and this sufficiently often, to unhesitatingly assert its existence. 
One positive fact is worth a dozen negative ones ; it not being always 
found, does not prove that it never exists ; and this is pretty m«ch 
the state of the question upon this point. We cannot possibly doubt 
its existence, because we have frequently seen it ; and if it do not 
prove to be universal, even where it might be reasonably expected, 
it should be recollected, that many causes may operate to its destruc- 
tion, without a vicious inclination, or moral turpitude, being of the 
number. 

101. Besides, we have lately seen an interesting report upon "the 
condition of the female genital organs at birth, by L. Senn, of la 
Maternite de Paris," in which he says, u in examining between three 
and four hundred children, from two to four years of age, I did not fail 
in a single instance to find the hymen." He adds, " l'hymen ne man- 
que jamais, et ne varie pas dans sa position ; mais il presente des dif- 

5 



42 OF THE INTERNAL ORGANS. 

ferences de form, qui influent specialment la figure et 1'entendue de 
l'overture, du vagin."* 

102. Immediately at the external extremity of the vagina, we 
may observe several small, fleshy, very vascular bodies, which seem 
to serve as valves to this orifice — these are the carunculse myrti- 
formes; and upon which, in the virgin state, the hymen appears to 
spread itself; and are considered, even now, by many to be the 
fragment, of this membrane — but these bodies exist independently of 
each other ; and are, besides, very much too large to be the debris 
of the hymen — their use appears to be, to hinder the urine, and even 
other foreign bodies, from passing into the vagina ; to contribute to 
the venereal orgasm ; to provide in the last moments of labour a 
supply of distensible material, and by this means diminish the risk 
of severe contusion or of laceration. 

103. In advance of the hymen, and a little below it, the semilunar 
fold, called the fourchette, may be seen ; it almost as certainly be- 
longs to the virgin as the hymen, as it is rarely found after 
delivery — between the hymen, and the fourchette the fossa navicu- 
lars is situated. 

104. The space directly behind the inferior terminations of the 
labia, and before the anus, is called the perinseum — in its -natural 
state it is about an inch and a half in width; is <pretty dense, 
though chiefly composed of cellular membrane ; but is capable of 
prodigious extension. 

Sect. I. — Of the Internal Organs. 

105. The internal organs of generation consists of the vagina, 
the uterus and its appendages, the Fallopian tubes, and the ovaria. 
The vagina is that canal which leads directly from the external or- 
gans to the uterus. I have already stated, (99) that the hymen in 
virgins, and the carunculse myrtiformes in married or used women, 
guard, as it were, the entrance of this canal. The length of the 
vagina may be stated to vary at different periods of life: it is wider 
at its upper extremity than below ; and more especially towards the 
sacro-iliac symphysis ; as its central portion is occupied by the uterus, 
which hangs pendulous in it. It is not direct in its course; it dips 
a little downwards at first and then passing upwards to meet the 
uterus, with which it is so united as to exhibit, in time of labour, no 
line or mark of union, forming, as it were, a continuous canal with 
this organ. It consists of a pretty dense cellular substance, which 
is very elastic, as is proved after deliverv by its quickly restoring 
itself. 

106. The vagina is lined by a continuation of the membrane which 
covers the internal face of the labia, and is called by some its villous 
coat ; this is the coat that presents itself externally through the ex* 
tent of this- canal. The other coat is more dense; and though not 

* Journ. Univ. de Med. Vol. xxvii. 272. 



OF THE UTERUS AND ITS DEPENDENCIES. 43 

possessed of traceable or distinct muscular fibres, is, nevertheless, 
very contractile, and hence the formation of the rugse of this part: 
the posterior face of this elastic, or if you please, muscular coat, is 
surrounded by cellular membrane, by which it is connected with the 
parts immediately in contact with it. These folds or wrinkles are 
called rugae — it is asserted by some, that these rugae are peculiar 
to women; and to which several duties are assigned: — 1st. That 
they contribute to venereal gratification (but if this were one of 
their offices, they are certainly ill situated.) 2d. That they serve 
as a remora* to the ejected semen, and at the same time offer it a 
larger surface to be absorbed from. 3d. That these folds serve to 
give greater length and breadth to the vagina, by stretching out 
during labour, and thus preventing laceration. The vagina is ex- 
tremely well supplied with blood vessels; and, when well injected, 
is found to be highly vascular — through its whole surface innumer- 
able glandular follicles may be seen, which constantly secrete a 
mucous fluid. The vagina in its course forms several points of ad- 
hesion by means of cellular membrane : — 1st. It adheres very strong- 
ly to the urethra before ; and 2d. Behind, it unites itself pretty firmly 
at its upper part to the rectum. Besides, there are two small glands, 
which Bartholine denominated vaginal glands — or the female pros- 
tates. Their uses are not accurately determined. Garter thinks 
they may give rise to, or have terminating upon them, the ducts he 
lately discovered; the purpose of which is to convey a portion of 
the ejected male semen to the ovaries. They most probably secrete 
the milky fluid discharged by the female during venereal gratifica- 
tion. A woman lately informed me she uniformly had an emission 
when she was receiving the highest gratification. She was a wo- 
man of exalted passions, and would sometimes from mere force of 
her imagination discharge this fluid so freely as to wet her linen 
considerably; I had frequent opportunities to observe it, it w r as 
slightly milky. By this discharge she felt completely for the time 
satisfied. 

This serves to prove that these glands perform a function connect- 
ed with venereal gratification and pleasure. The woman just 
spoken of, had a diseased uterus — but the discharge took place 
notwithstanding; it was a normal condition with her, and she 
viewed its occurrence as a proof that the w r omb was not diseased 
for she thought if it were she would not have these feelings. 

Sect. II. — Of the Uterus and its Dependencies. 

107. The uterus is situated in the pelvic cavity, at the upper ex- 
tremity of the vagina ; it is so placed as to have the bladder before, 
and the rectum behind, it ; and with both of which, there is more of 
less intimacy of connexion, by intervening cellular membrane and 
reflected peritoneum. It is of a pear-like shape, but a little flattened ; 

* Speculations on Impregnation. 



44 OF THE UTERUS AND ITS DEPENDENCIES, 

and has its small extremity hanging into the vagina. It has been 
usual with writers, for the sake of convenience, to divide this organ 
into three parts ; namely, fundus, body and neck- — the fundus is made 
to consist of all that portion that is superior to the origin of the Fal- 
lopian tubes ; the body, of the part inferior to them, and extending 
to the commencement of the neck ; and the neck, of all that accumi- 
nated portion which distinctly dips into the vagina, and terminates in 
the os tinea?. 

108. The substance of which the uterus is composed, has long 
been a matter of dispute with anatomists and physiologists — some 
declaring it to be muscular, while others insist it is in its structure, 
sui generis. Mr. Bell* decides on the muscularity of this organ, be- 
cause he has seen and dissected its fibres ; so did Vesalius, Mal- 
pighi, Ruysch, Hunter,f &c. While Dr. RamsbothamJ denies the 
fact; and says, " this notion appears to be rather an assumption de- 
rived from the contractile powers, which this viscus is known to pos- 
sess, and which are supposed only to exist on muscularity, than to 
originate in obvious appearances. However authors may write, and 
teachers may talk about the uterine muscles, no such structure is evi- 
dent to my senses." Neither this declaration of Dr. R. nor his rea- 
soning on this point, has in the slightest degree shaken my faith in 
the muscular structure of this organ — the whole phenomena of la- 
bour at full time, and the throwing off" of the ovum in aborting, irre- 
sistibly force me to this opinion. It is not at present, and perhaps it 
never may be decided in what manner the fibres of the uterus dis- 
pose of themselves in composing this organ ; yet enough of its struc- 
ture is known, I believe, to warrant the declaration, that its functions, 
as regards labour, are performed by the power of muscular contrac- 
tion. 

I shall avail myself of the judicious observations of Velpeau upon 
the subject of the muscularity of the uterus, as we think they must 
carry conviction to the mind upon this often contested subject. 

"Previously to asserting that the womb does, or does not, contain 
muscular tissue, it would have been proper to determine what are the 
characters of that tissue in general ; to show that the red colour is 
not essential to it, since it is wanting in the muscles of fishes, rep- 
tiles, and even in the muscular coat of the human intestines ; and 
that the same is true of the fibrous appearance, since it is met with 

* Eclec. Rep. Vol. V. p. 37. 

t Velpeau, agreeably to his own declaration, has dissected very many uteri at every 
period of life; he has examined them when impregnated and when unimpregnated. 
From these examinations he is led to the following results : 1st, that there is a thin, 
elastic, cellulo-fibrous structure immediately below the peritoneal covering of this or- 
gan ; this is sometimes, but not always muscular; but in which, there is no determi- 
nate arrangement of fibres. 2clly, A thick layer of fibres, the direction of which is 
transverse. 3<ily, Other transverse fibres are found situated more deeply — but the lon- 
gitudinal and oblique fibres predominate, particularly at the neck. And above is seen 
the supposed detrusor placenta of Ruysch, which appears to be no more than an expan- 
sion of the circular fibres belonging to the Fallopian tubes. Art des Accouchemens, 
torn. 1, p. 84. 

X Practical Obs. Am. ed. p. 19. 



OF THE UTERUS AND ITS DEPENDENCIES. 45 

in the tendons, aponeuroses, &c, but that it alone enjoys the faculty 
of contractility, and contains fibrine. 

" In the second place, it should be considered indispensable to re- 
cognise a truth that is too much overlooked in our days ; which is, 
that the fleshy fibre must necessarily pass through several less perfect 
gradations of development; that, in some organs, it remains in the 
rudimental condition, and is developed only by accident. Thus, the 
trachea, and the bronchia, even the arteries of large animals, the ele- 
phant among others, evidently exhibit muscular fibres, while the same 
organs in the human species rarely exhibit them with any distinctness. 
The gall bladder, the vesicuke seminales, &c, are not furnished with 
them, according to most of the modern anatomists ; but let these or- 
gans be examined when their coats, strongly hypertrophied, have 
been long distended, and we shall soon be "forced to admit that they 
possess a muscular coat, as the ancients believed, and as I have seen 
myself. The womb, previously to puberty, is only a rudimental mus- 
cle ; when not gravid, its organization, it is true, is but a sketch, but 
it is only towards the end of pregnancy that we can possibly test its na- 
ture. Every circumstance tends to establish that the cellulo-fibrous, 
elastic yellow tissue, which composes the basis of the inter-laminar, 
and inter-spinal ligaments of the vertebrae, constitutes also the web 
of a very great variety of other organs. It is no where more abun- 
dant than in the uterus. Hence, it appears that this element holds a 
middle place, and serves in some sort as a passage between the cel- 
lular and muscular system; the chemists have detected fibrine in it, 
and I have seen it, on various points, transformed into real contractile 
tissue. I am scarcely afraid to assert that wherever it is met with, 
it may accidentally develope muscular fibres, and that these fibres ex- 
ist naturally in some zoological species. 

" In order therefore to understand the essence of the uterine tissue, 
it ought to be studied during its gravid state ; then, only, is it red, 
contractile, formed of tormentous fibres, then, only, does it contain 
a large portion of fibrine : and presents, in a word all the characters 
of the most perfect muscular tissue."*! 

* Dr. Meig's translation, p. 63. 

+ Dr. Blundell says that in the rabbit, the muscular fibre is much more obvious than 
in the intestines. Then why may it not be given to the human uterus, if the uteri of 
animals possess them 1 — Princip. and Pract. of Obstet. p. 81. He also urges the fol- 
lowing, in proof of this muscularity: 

M 1 h it the human uterus is muscular, appears when it is developed from pregnancy ; 
and this is so clear, that, if you take a piece of the uterus thus developed, and show it 
ivitomist or demonstrator, asking him, at the same time, what it is, he will re- 
dout hesitation, that it is muscular, fi. The very appearance shows it to be a 
r structure, when thus developed. 3. But there is another proof of uterine 
muscularity ; namely, it contracts like a muscle under the excitement of a stimulus." — 

This fact should be decisive; for we have known it to contract a thousand times 
under the influence of a stimulant. Now, there is no other modification of the living 
tissue will do this. The only property of this kind that we know is one common to 
■even! forms of matter, namely, elasticity ; yet the modifications of living structure. 
so called, never contract by stimulation. " 

&• 



46 OF THE UTERUS AND ITS DEPENDENCIES. 

109. There is no organ in the human body, from whose structure 
so little can be inferred, as the unimpregnated uterus; in it, when 
laid open by the knife, we see no manifestation of capacity for dis- 
tention ; on the contrary, we observe nothing but dense unyielding 
walls, that would seem to bid defiance to any attempt for thispurpose 
— in it we have no promise of the enormous force which it is des- 
tined to exert, to ^relieve itself of the produce of conception — nor 
can we anticipate the immense distensibility of its vessels from preg- 
nancy, in the diminutive, nay, almost imperceptible ones in its empty 
state — so wonderful and so varied are the changes which this organ 
undergoes from impregnation. 

110. The cavity of the uterus is small and somewhat of a triangular 
form ; it terminates below T in the neck, and its opening is termed theos 
tincse. The uterus is lined through its whole extent, by a fine mem- 
brane, which, from near the os tineas to its fundus, and the windings 
of the Fallopian tubes, is so completely identified with the proper 
substance of this organ as to defy any attempt at a regular separation 
— the same may be said of its peritoneal covering ; refusing to dis- 
solve its union with the external portions of the body and fundus, by 
any attempt that may be made for the purpose, until after incipient pu- 
trefaction. 

111. It is said by all the writers that recognise this membrane, so 
far as I know, that the w T hole of the internal surface of the uterus, in- 
cluding the neck of this organ, and the Fallopian tubes, is furnished 
with linings, from a continuation of the membrane which gives cover- 
ing to the vagina — I have strong reasons to call in question the truth 
of this supposed arrangement ; so far, at least, as the absence of 
identity of function will declare the absence of identity of structure 
— it is now no longer a matter of dispute, that it is from the inter- 
nal face of the uterus that the menstruous secretion proceeds ; yet this 
fluid is neither furnished by the vagina, nor by the Fallopian tubes ; 
consequently, the membranes lining these parts, cannot be precisely 
one and the same. I assume here the positive side of the question 
respecting the internal face of the uterus possessing a membrane, 
notwithstanding the cavils upon this point, by several late eminent 
anatomists. As far as authority will justify the assumption, it cer- 
tainly appears to be in favour of the belief. For though Ribes, 
Chaussier, Gordon, and Madame Boivin, deny its existence, others 
insist upon it. Dr. Francis of New York assures me lately that he 
had a preparation demonstrating its existence ; and Velpeau* asserts, 
unequivocally, its presence in the following words : — 

112. " II est vrai que, hors de temps de la gestation ; on ne peut 
pas toujours demontrer ^existence de la membrane muqueuse uterine; 
mais chez plusieurs femmes, mortes encientes ou peu de temps apres 
lacouche, je suis parvenu a en enlever des lambeux tres-distinets. 
Quand meme on ne pourrait pas l'isoler meehaniquement, Panalogie 
sufhrait pour convaincre de sa presence ; les membranes muqueuses 

* Art des Accoachemens^ Vol. I. p, 77. 



OF THE UTERUS AND ITS DEPENDENCIES. 47 

sont exclusivement pourvues de villosites ; elles fournissent settles du 
mucus, dans l'etat sain, des mucosites purulentcs dans l'etat patholo- 
edque ; c'est a leur surface qu'on voit paraitre les polypes, les exha- 
lations sanguines.' 7 In a word, we think the existence of this mem- 
brane cannot be denied, as we have seen it ourselves, after delivery, 
in several instances ; but it differs from other mucous membranes, in 
being deciduous. » 

113. The division of the uterus into different portions, was sug- 
gested for the convenience of demonstration, and has been employed 
by all the writers upon anatomy and midwifery, for the last century, at 
least. I adhere to this division, but from very different motives ; 
many year.s ago, I insisted on this division as essential to the expla- 
nation of several of the phenomena, which this organ was constantly 
presenting ; I shall therefore transcribe, without apology, my senti- 
ments, as expressed upon this subject, from my " Essay on the means 
of lessening Pain, and facilitating certain Cases of Difficult Labour," 
p. 17, ed. 2d. 

114. "I cannot help regarding the neck of the uterus as a distinct 
and independent part from its body and fundus ; having its own pe- 
culiar laws and actions : and that this separation of powers is abso- 
lutely necessary to the explanation of some of the phenomena 
exhibited in health and in disease, as well as the influence of certain 
agents upon this organ. 

115. "My reasons for thinking so, are, first, that we find the fundus 
and body may be distended to a great extent, without affecting the 
arrangement of the neck; thus, in every uterine pregnancy, we see 
these parts gradually yield to the influence of the ovum, until about 
the sixth or seventh month: while the neck remains very much the 
same as before impregnation. 

r 116. " Secondly, that after the sixth or seventh month, the neck 
undergoes its changes; while the fundus and body remain in a great 
measure stationary; so that two distinct processes, or rather the same 
process, is performed at two different periods, and in different parts, 
in the order we have just mentioned.. 

117. " Thirdly, that the neck maybe affected by disease, while the fun- 
dus and body may remain free, and the reverse ; and that the neck may 
contract and relax, while the other parts are in opposite states — thus, 
with women who are in the habit of aborting from some constitutional 
peculiarity of the uterus, we find the body and fundus can be called 
into action, while the neck for a long time remains passive ; and also 
the neck may relax, and, after some time, the fundus and body may 
be excited to contraction. And in cases of atony of the uterus after a 
too sudden delivery, or any other cause, the body and fundus may 
contract, while the neck is the only part in fault, and vice versa. 

118. " The different conditions of the several parts of the uterus 
may be in at one and the same time, where atony prevails, partially, 
would seem to demonstrate the truth of what is here advanced. For 
it is a fact well known to almost every practitioner of midwifery, that 



48 OF THE UTERUS AND ITS DEPENDENCIES. 

each of the parts into which we have divided this viscus, may 
separately and independently of the other parts be in a state of 
relaxation, or contraction, and thus exhibit different phenomena, and 
be productive of different results." From this it would appear that 
nature has really established a division of the uterus, which has hitherto 
been considered as merely conventional. For the most part the ute- 
rus has but one cavity, but cases of double uteri are upon record : thus, 
Lobstein mentions the case of a woman who had two distinct uteri. 
Vallesneri dissected a female in whom were found two uteri ; the ori- 
fice of one opened into the vagina, the other into the rectum. 

119. Another case is recorded of a double uterus, in a woman 
"who died of peritoneal inflammation soon after the birth of her fifth 
child ; she was thirty years of age. Her first delivery was laborious ; 
the three succeeding ones natural. With the fifth she died soon after 
its delivery. The uterus was found to consist of two lobes ; one more 
anterior than the other. The right lobe had evidently contained the 
last foetus. It was probable that the first children were contained in 
the left lobe. The vagina was single." (Med. Chirur. Rev. Sept. 
1823.) 

One of the most remarkable instances of the vagaries of nature in the 
formation of the uterus, is that related by Chaussier; (Bulletin de la 
Facul. de Med. for 1817.) A woman in the Maternite of Paris was 
delivered of her tenth child, in whom, after death, it was found that 
the right side of the uterus only existed, with one ovarium and one 
tube. 

120. Lobstein supposed that two uteri were necessary to super- 
foetation ; here is at least a recent instance in which this did not take 
place, though each uterus was in turn impregnated. We mention 
these instances from among many other deviations of this organ, 
which may truly be said, to have almost as many conformations as 
any other important viscera in the body. To prove this we need but 
consult M. Martin's paper on this subject, in Revue Med. Vol. 3d, 
p. 51. 

121. Fallopian Tubes. The uterus may be farther divided into an 
anterior and posterior surface, and into two sides. The anterior por- 
tion of the uterus is rather more convex and thinner than the posterior, 
and is subject to a less degree of distention — the posterior yielding 
considerably more, during the progress of gestation ; and for this pur- 
pose more substance is given to it. From each side of the uterus,, 
and at a line which would divide the fundus from the body, a tortu- 
ous body takes its rise ; and is named the Fallopian tube ; it ishollow; 
but its calibre is not of a uniform width ; at its uterine extremity, the 
opening is very small; but as it proceeds, it acquires size, and eventu- 
ally terminates in an opening of some capacity, which is surrounded 
by an uneven frill, called the fimbria. 

122. It has been thought by some that these tubes were composed 
of similar tissues with the uterus itself; it is denied by others ; but all 
agree that they enjoy a vermicular motion. Their linings are also 



OF THE UTERUS AND ITS DEPENDENCIES. 49 

said to be continuations of the same membrane which lines the ute- 
rus ; but I have already called this in question (111) — the internal 
membrane of each tube is contracted through its whole length into 
longitudinal plicae ; and furnishes, by means of many little glands, a 
fluid which constantly lubricates its surface. 

123. Ovaries. Near to the abdominal extremities of the Fallopian 
tubes we find two small roundish bodies called the ovaria: these 
glands, if we may so term them, are of primary importance to the ge- 
nital system of the female. By them is given the first impulse for the 
menstruous secretion, and venereal indulgence ; by them is furnished 
whatever may be contributed by the female towards the formation of 
a new being.* They are about the size of a common nutmeg, 
if it were a little flattened ; and when cut into, present a glandular 
appearance — they are not remarkably supplied with blood vessels,! 
nor do they possess much sensibility. At puberty, we may remark 
upon their surface, and especially when favourably placed between 
the eve and the light, a number of little vesicular bodies of uncertain 
number, which contain a fluid, capable, it is said, of being coagu- 
lated — these are the ova. These are the vessels of De Graaf, and are 
in number from ten to twenty. It would be difficult to ascertain the 
number of the ova, or the vesicles of De Graaf, otherwise than by a very 
general average of such ovaria as may have been examined, which 
bears no proportion scarcely to such as have not been examined; and 
it would scarcely be possible to make an estimate, by taking the 
average of the children each woman may have during the period she 
was subject to child-bearing ; for this would only express the abso- 
lute number, without being able to ascertain the cavity of all such 
as may not have had their ova called into action. That they are much 
more numerous in some women than in others, we cannot doubt, and 
if we are to adopt this rule from the number of children borne by 
such individuals, as have had every reasonable opportunity to have 
their ova called into action, we would say there might exist from one 
to thirty-two; for this last number of impregnations I am indebted to 

* By the older anatomists, they were supposed to furnish a fluid similar to the se- 
men of the male : and hence were termed' testes muliebres. But this analogy is alto- 
gether gratuitous ; as their structure is their own, and peculiar as each important organ 
must be, cs it has its own specific r6le to perform, in the animal body.. 

t Notwithstanding this poverty of vascularity, we are told of a "fatal haemorrhage 
from the rupture of the Fallopian tube. As the case is both uncommon and interest- 
ing, we will give it as recorded in the Jour. Univera. 

44 A woman lived upon bad terms with her husband, who one evening, during a vio- 
lent quarrel, threw a chair at her with all his force. She was seized with a violent 
colic early next morning, attended by an alarming purging and vomiting. The belly be- 
gan to swell after these symptoms had shown themselves ; and after thirteen hours of 
illness she died in convulsions. In consequence of suspici >n that she had died of 
. the body was taken up after it had been ten days buried, and carefully examined 
by order of the proper authorities. It was found fresh, and free from contusions or 
lividity. All the organs in the head and chest were found sound, as well as the ali- 
mentary canal; but the belly contained a large quantity of serous fluid and coagula, 
to the amount of eight pounds or more. And after a careful search, it was found to 
proceed from a perforation in the right Fallopian tu.be> near its attachment to the uterus.** 



50 OF THE UTERUS AND ITS DEPENDENCIES. 

the lady to whom this number happened. She had borne eleven 
children at full time, the remaining number was twenty-one abortions, 
from the third to the seventh month.* Nor would it perhaps be fair 
to limit the number, as we are by no means certain that the ovaries 
may not have the power to form them ad libitum. According to De 
Graaf, both blood-vessels and nerves spread themselves upon their tu- 
nics, in a manner similar to that which takes place upon the yelk of 
an egg, while it preserves its attachment to its ovary. There is little 
question now, that the ovaries furnish the ovules — -at least if any de- 
pendence can be placed upon the observations of Prevostand Dumas. 
They declare they always exist in the ovaries of the adult female ; 
but cease to be formed in old age. Animals that copulate at all sea- 
sons, have them constantly during the period they are capable of 
be^ng fecundated ; while such as have a stated period, as once a year, 
have them only during the period of heat. When these are displaced 
by either fecundation or otherwise, they leave evidences, that they oc- 
cupied certain portions of the surface of the ovaria. 

124. We may also remark upon the face of the ovarium, a num- 
ber of little spots, which, from their colour, are named corpora lutea ; 
these until lately, were supposed to be the cicatrices of removed ova ; 
but Sir E. Homef has pretty satisfactorily proved, that these marks 
exist previously to impregnation; and that they have no less a des- 
tiny, than to furnish the ovum, and prepare it for impregnation. In 
the virgin- state he declares a corpus luteum, to be a solid compact 
glandular body ; and when the ovum is liberated, the cavity it leaves 
is filled with blood; which after awhile is absorbed, and a small pit 
remains. 

125. Dr. Plagge, of Benthiem, has lately been investigating the 
formation of the ovum in the mammalia. He entirely agrees with 
Sir E. Home and Mr. Bauer, as to the formation of the ovum in the 
ovary before impregnation ; but he thinks he has discovered, that in- 
stead of being formed in or by the corpus luteum, as affirmed by 
these gentlemen, the ovum, as well as the corpus luteum, are formed 
in the vesicles of De Graaf; and that the corpus luteum bears the same 
relation to the ovum in the ovary, as the placenta does afterwards in 
the uterus. He observed, that a little areola first appears on the mem- 
brane of the vesicle ; and not long afterwards, the rudiment of the 
future ovum may be seen like a gray speck in the middle of this areola, 
and on the inside of the vesicle. After the rudiment has increased 
till its diameter is equal to three lines, (in the cow,) the corpus luteum 
begins to appear on the peduncle of the rudiment, betwixt it and the 
membrane of the vesicle, and the ovum is thus gradually pushed to- 
wards the surface of the ovary, to be impregnated. (Jour. Comple- 
mentaire, &c.) 

126. The whole of the abdominal portions of the uterus, namely, 
the fundus and body, are covered with peritoneum — and as it passes 

* See par. 1336. t See Phil. Trans, years 1817 and 1819. 



OF THE UTERUS AND ITS DEPENDENCIES. 51 

from the sides of this organ, it forms a duplication towards the lateral 
portions of the pelvis ; and makes what has been termed the broad 
ligaments — each of these ligaments has an anterior and a posterior 
portion or pinion — in the anterior pinions, the Fallopian tubes are in- 
cluded ; and in the posterior, the ovaria. 

127. The round ligaments, two in number, originate from the su- 
perior lateral parts of the womb, and run in the doublings of the 
broad ligaments ; they then rise to the brim of the pelvis, pass over it 
through the abdominal rings, and lose themselves as it were in the 
groin. These ligaments are extremely vascular during pregnancy ; 
and it is to the engorgement of them, that Baudelocque attributes the 
pain the woman sometimes feels in these parts as gestation advances. 
These two sets of ligaments have been supposed to give support, or 
permanency of situation to the uterus ; if this be the design of them, 
it must be confessed they perform their duties in a very inefficient 
manner — for it is well known to every accoucheur, that nothing can 
be more uncertain than the situation of this organ ; for every change 
in the abdominal viscera, every alteration in the contents of the blad- 
der and rectum, imposes upon it a new position. Mr. Charles Bell 
has, however, made a new, and what he seems to think, an important 
suggestion, as to the offices of the round ligaments ; he supposes they 
give rise to a number of muscular fibres, which perform a very impor- 
tant role in the economy of gestation, and of labour ; while, at the 
same time, they perform the offices of tendons rather than of ligaments. 
I shall refer the reader, for a consideration of Mr. B's opinions upon 
this subject, to "Essays upon various Subjects connected with Mid- 
wifery," by the author, p. 461 et seq. 

128. The uterus is supplied with blood vessels from the spermatic, 
and hypogastrics. These arteries are divided into two orders by 
some — the first supplies the substance of this organ by penetrating it 
at the neck ; the second, are those given off by the aorta, or emulgents ; 
and after supplying the ovaries and broad ligaments, run to the sides 
of the uterus itself. The anastomoses of these arteries are very fre- 
quent, and the two sides of the uterus reciprocate in their distribution 
and union — thus the arteries of the right side unite very frequently, 
and intimately, with those of the left; while those from the fundus join 
with those of the cervix. They pass in such a manner as to be much 
convoluted, and Jo suffer strong compression from the substance or 
tissue through which they are transmitted. The veins observe a simi- 
lar distribution, and eventually pass on the internal iliae and ovarian 
veins. The intercostal, the renal plexus, and sacral, furnish it with 
nerves. Mr. Hawkins informs us, that " the nerves of the human 
uterus are supplied from six different plexuses. The spermatic plex- 
us within the abdomen ; the great hypograstric plexus between the 
common iliac arteries ; and four within the pelvis ; two of which are 
situated on each side of the uterus. All of these have the peculiar 
appearance of the sympathetic nerve, and they are intimately con- 



52 OF THE EFFICIENT AND FINAL CAUSE OF THE MENSES. 

nected with all the other nerves of the vicera."* There are a number 
of nerves that spread themselves on seveal portions of the internal 
face of the pelvis, some of which may be powerfully impinged upon 
during the passage of the child, as when the relation of the head is 
very strict to the diameters of the pelvis. As the anterior crural, ob- 
turator, the sciatic nerves, &c, are, or at least part of them, but ill- 
protected under some circumstances, against pressure from the child, 
or from the application of forceps, we have seen a case where from 
the former cause, the most violent and fearful cramps ensued the 
moment the child's head entered the superior strait, and thus instantly 
suspended the contractions of the uterus ; this has obtained with each 
child the lady has borne up to this time. In each of these cases I 
was obliged to deliver with the forceps. From the second cause 
(forceps) every practitioner, who has frequently employed these in- 
struments, must have observed very distressing cramps from their 
application. And every body must have witnessed these cramps when 
the head of the child is large, either relatively or positively, when the 
face is about to sweep into the hollow of the sacrum, while it is ex- 
ecuting its pivot-like motion, from the head pressing upon the sacral 
nerves especially ; and by the leg and thigh that are cramped, we 
may almost always decide whether the presentation is the first or 
second of Baudelocque and of the arrangements of the authors. It is 
almost abundantly provided with lymphatics. f Having thus, in a 
cursory manner, given the anatomy of the uterus, it w T ould seem 
proper that its functions should next be considered ; and first — 



CHAPTER IV. 

OF THE EFFICIENT AND FINAL CAUSE OF THE MENSES. 

129. By menses we mean the periodical discharge of a coloured 
fluid resembling blood, happening every lunar month ; commencing 
at puberty, and continuing until about the forty-fifth or even fiftieth 
year, unless interrupted by pregnancy, suckling, or disease." 

130. It was formerly a matter of doubt from whence this discharge 
proceeded ; some supposed it came from the uterus itself and others 
from the vagina, or both. This question is now put to rest ; Morgagni, 
Dr.. William Hunter, and others, having seen it proceed from the os 
uteri, in cases of procidentia. It was also a matter of much uncer- 
tainty, which class of blood vessels furnished this fluid: Ruysch de- 
clared it to be from the arteries; Vesalius from the veins; and Simpson 
from certain appropriate sinuses. If the views I shall take of this in- 

* Fhilosoph. Trans. 1825, p. 70. f Cruikshank on the Lymphatics. 



OF THE EFFICIENT AND FINAL CAUSE OF THE MENSES. 53 

teresting phenomenon be correct, namely, its being a secretion, it will 
be found to proceed, most probably, as Ruysch supposed, from the 
arteries, as all the secretions, so far as we yet know, with the excep- 
tion of the liver, are performed by arteries.* 

131. It is uncertain who first suggested the idea, that the men- 
struous discharge is a secretion — the credit of it has been given to 
Haller, Bordeau, Hunter, and Saunders — the latter unquestionably 
taught it publicly in 1784, and how long before, I cannot ascertain ; 
but this is now of little consequence. 

132. I have, however, ascertained that the doctrine of secretion is 
of pretty ancient date. It is mentioned by Ramazzini in unequivocal 
terms as a secretion, as the following passage declares: — " Il-y-a tout 
lieu de croire que le sang des regies a quelque qualite maligne et 
cachee ; et on lui a donne a juste titre le nom de secretion et excre- 
tion." In this extract, the term " secretion" appears to be familiarly 
used; and one most probably employed in common parlance. And 
Fourcroy, the translator of this work from the Latin, in a note to a 
part of the paragraph from which the above extract is taken, says, 
11 Rien cependant n'etoit plus naturel, sans avoir recours aux pheno- 
menes, ehymiques, que de concevoir le flux des regies, comme une 
secretion qui a son organe, ses periods reglees, sa marche et son de- 
partment, ainsi que toutes les autres secretions!." Ramazzini's w r ork 
was first published in 1700; consequently, the suggestion of the 
menses being a secretion cannot belong to either Haller, Bordeau, or 
Hunter; indeed, it would seem from the manner in which it is men- 
tioned, to have been taught before this period, as no claim of origi- 
nality is preferred. 

133. Independently of the evidence derived from the structure and 
diseases of the uterus, that the menses are the result of a secretory 
process, we are to regard the appearances of the discharged fluid itself, 
as confirmatory of the suggestion. This discharge must be either a 
portion of the common mass of blood as it circulates at large in the 
system, or it must have undergone some change during its separation 
from the common mass — if the former, it should exhibit the appearance 
of blood detracted from any other part of the body by opening a vessel 
for the purpose ; but this is not so ; if the latter, it is probable that it 
has been eliminated by that process termed secretion. This opinion 
is farther strengthened by the following considerations of the physical 
properties of the fluid itself: 1st. Its colour is between the arterial 
and venal blood ; being less brilliant than the former, and more florid 
than the latter: 2dly, It never separates into parts; blood drawn, or 
evacuated from any other part of a healthy body, does separate, in a 

* The truth of this last assertion, however, has been lately called in question by Dr. 
Holland, from Mr. Abcniethy having met with an instance of the secretion of bile 
where there was no v- na porta; and that, in the whole of the molluscre, the liver is 
very large, and is supplied by the aorta alone. — Dr. Holland on the Physiology of the 
Foetus Sfr. 

t Rammazzini, Essai sur les Maladies des Artisans, traduit du Latin, par M. de 
Fourcroy, p. 215. 

6 



54 OF THE EFFICIENT AND FINAL CAUSE OF THE MENSES. 

short time, into its principal component parts : 3dly, It never coagu- 
lates, though kept for years;* while other blood, when free from dis- 
ease, quickly does, when exposed to the influence of the air : 4thly, 
Its odour is remarkably distinct from that of the circulating mass ; and 
it is less disposed to putrefaction. 

134. It is thought, by some, to differ materially from common 
blood, from it not possessing fibrin; of this I cannot speak w T ith cer- 
tainty ; but I am disposed to believe, that this part of the blood has 
only undergone a change during elaboration; more especially, as the 
coagulating lymph is always found to accompany the red globules, 
whenever blood has been accidently extravasated, or designedly 
drawn ; my reasons for thinking that the fibrin of the blood has only 
suffered an alteration of property, and that it is constantly present in 
the menstruous blood, but is altered, are, that, in many instances, 
nothing more is necessary to this effect, than the establishment of 
some peculiar arterial action — thus, w T e find, in certain kinds of small- 
pox, fevers termed putrid, scurvy, &c, the blood loses the power of 
coagulation ; the blood of those who die from lightening, blow T s upon 
the stomach, &c, it is said that the coagulating lymph loses the ca- 
pacity to coagulate — therefore, the mere absence of coagulability, is 
not sufficient to prove the absence of fibrin. 

135. In this, nature has shown her benificence ; for to w T hat wretch- 
edness would the woman be doomed at each menstrual period, did 
it retain its property of coagulation ? Mr. Hunter thought that the 
property of coagulation was lost from the blood losing its living prin- 
ciple during the secretion — but to this we cannot subscribe ; as this 
fluid, as has already been noticed, is thought to resist putrefaction 
longer than common blood. 

136. I have stated in the definition of u menses," that it first takes 
place at puberty, or that period at which the animal is capable of pro- 
pagating its species — this period must vary as it may be influenced 
by climate, constitution, and modes of life ; always being earlier in 
hot than in cold countries ; sooner in cities than in the country, &c. 
Before they make their appearance, they almost always announce 
themselves, in the altered appearance of the female — the mammae in- 
crease in size ; the voice undergoes a slight change : the pubes are 
covered with hair ; and the best proportions the individual is suscepti- 
ble of, are now suddenly and successfully developed. The mind also 
replete with changes ; puerile amusements now yield to maturer enjoy- 
ments, and rational inquiry; capricious attachments give place to sin- 
cere, unaffected, and permanent friendship ; in a word, a new creature, 
almost, seems to be suddenly formed. Besides the physical and moral 
changes just spoken of, there are other circumstances, which mark the 
pubescent period to be near at hand — such as headach, dullness of the 
eyes, pains in the pelvic region, lassitude, whimsical appetite, slight 

* My friend, the late Dr. Physick, informs me, that Dr. Clark, of London, used to 
exhibit a vial of menstruous blood which had long been in his possession, but which 
had never separated into its component parts. 



OF THE EFFICIENT AND FINAL CAUSE OF THE MENSES. 55 

leucorrhoe, &c, and after these have continued a longer or shorter 
time, they suddenly depart, and a discharge of a small quantity of 
fluid from the vagina, and this not necessarily coloured at first, is 
found to have taken place. The last named circumstance is worthy 
of attention ; as it will serve to explain those cases of impregnation 
which are said to have taken place previously to the eruption of the 
menses. 

137. The menstruous period is usually from four to six days; and, 
during this time, from four to six ounces of fluid are discharged — in 
tins there must necessarily be* some variety ; depending upon consti- 
tution, &c. After it ceases, the woman is exempt from a repetition, 
for twenty-eight days or a lunar month less the time it is flowing; but 
at which time it returns with distinguished regularity — so much so, 
indeed, with some women, as to enable them, not onl}*to indicate the 
day, but also the hour — during the flow, the appetite, with'some, be- 
comes capricious ; they are languid, pale, or hectically florid ; a dark 
stripe most frequently may be observed below the eyes ; and with 
many, a dragging sensation is felt aboutthe hips and loins, during the 
whole period. 

13S. In this manner are women subject to this flux, until between 
the fortieth and fiftieth years ; at which time they cease, never to re- 
turn. For the most part, as the period of cessation approaches they 
fail in their wonted regularity — sometimes the period is protracted to 
six or seven weeks, and then instead of five or six ounces being evac- 
uated, there may be a loss of twenty or thirty ; or there may be merely 
a show as it is termed — at other times the period may be anticipated 
by as many days as it had exceeded before ; and the discharge mav 
be as vague as I have just mentioned. 

139. I have known several instances, where the eruption of the 
menses was constantly preceded by strong hysterical paroxysms, of 
greater or less permanency ; the menses would now appear, and in- 
stantly the system would be tranquillized, and the woman return to 
her ordinary state of health. In one case, a severe pruritus accompa- 
nied this convulsive state to the great annoyance of the poor young 
woman who was the subject of it.* 

140. From the earliest records of medicine to the present day, the 
ingenuity of the philosopher has been exercised to point out the effi- 
cient cause of this peculiar habit of the human female ; I shall there- 
fore cursorily pass in review the various hypotheses which have been 
invented for this purpose, and, first : — 

* This young woman was perfectly relieved from these disagreeable symptoms, by 
camphor in ten grain doses,* at the commencement of the menstruous period, and 
liberally washing the parts in the interval wilh a strong solution of borax. 

* Th* writer of the Critical Analysis of Dr. Dewpes on Midwifery, in the London Med. & Phys. 
Jour, for Jul v, p. 72 say?, 'We should be unwilling to jrive ten grain* at B dote (of camphor) 
without having first tried, by the exhibition of a Bmaller quantity, the power of the patient to bear 
the ram 

I can assure the centleman. that I rarely, if ever, give this medicine in smaller doses; nor 
I f vcr witnessed the smallest inconvenience to follow, which was attributable to the large, 
ness of the dose. Idioayncracy may make any quantity improper. 



56 THE GENERAL PLETHORA DOCTRINE. 

Sect. I. — Of Lunar Influence, 

141. The influence of the moon was very early assigned as the 
efficient cause of menstruation : from either the real or supposed effects 
of this luminary upon the tides and diseases, it was easy to believe it 
might have a power or control over some of the healthy functions of 
the body ; and as the menstruous flux was periodical, and observed 
a lunar period, or interval, it was no great stretch of the imagination-, 
to suppose its return connected with the movements of this body ; 
this opinion is not entirely exploded at the present moment ; though, 
to destroy this hypothesis, it is only necessary to state the fact, that 
there are women menstruating promiscuously every day of the year, 
and every hour of that day. Galen, at an early period, saw the weak- 
ness of this scheme, and accordingly invented another ; namely, 

Sect. IL — The General Plethora Doctrine. 

142. This hypothesis has higher claims to our attention than the 
one we have just been considering ; for it is both ingenious and plau- 
sible. He began with stating, 1st. That women were more disposed 
to plethora than men : 2d. That to get rid of this superabundance of 
blood, some outlet was necessary, and that this outlet was the uterus; 
3d. That this state of fulness was essential to the female system, as it 
must make provision for the child, while in utero, as well as provide 
its sustenance after it is born ; and that these objects were effected by 
the suppression of this discharge during pregnancy and suckling ; 4th. 
That when the uterus failed in destroying the plethora, by yielding the 
menses, some other part performed a vicarious office, and gave issue 
to the blood : hence, hemorrhages from the lungs, bowels, ulcers, &c. ; 
5th. That when this evacuation failed to appear under ordinary cir- 
cumstances, the quantity of blood was below the ordinary standard ; 
and that it could only be recalled by such remedies as would increase 
the measure of this fluid. 

143. To the first of his positions, it may safely be said, that strong 
doubt must be entertained of the fact ; for, though women may exer- 
cise less than men, they perspire more ; and their ingesta is certainly 
less. 

144. And if there be a plethora, it must be occasioned by five or 
six ounces of blood ; yet, it is well known, that if five times that quan- 
tity were drawn just before the period was expected, or during its 
flow, that it would neither prevent the eruption, nor diminish the 
quantity that would otherwise be expended. Of this I am certain, 
from the following facts : — Many years since, I witnessed a singular 
periodical hemorrhage, which was of several month's duration, from 
the ear of a young lady ; it would commence at about 11 o'clock, 
A. M., every day, with the utmost regularity, and, after giving issue to 
an ounce or two of blood, it would spontaneously stop, and not recur 
until the same hour of the next day : yet this young lady menstruated 
with the utmost regularity, both as to period and quantity. It may 



THE GENERAL PLETHORA DOCTRINE. O I 

not be uninteresting to state, that this affection was cured by the ap- 
plication of a blister near the part, after very many other remedies had 
fruitlessly been tried. Another case fell under my observation, which 
goes still farther to prove that general plethora has no agency in the 
production of the catamenia. A young lady asked my advice for a 
daily discharge of blood from the anus, of several year's continuance : 
she would lose, very frequently, from half a pint to a pint at a time, 
and smaller quantities almost daily ; she, of course, was feeble, and 
far removed from plethora ; yet she menstruated regularly, and never 
employed less than a week for the discharge. 

145. To the second, it may be answered, that men, however ple- 
thoric, have no such compensating discharge.* To the third it may 
be declared, the means are not adequate to the end, for the embryo 
would not require, for a long time, any thing like five or six ounces 
of blood for its support ; and, at a more advanced period of gestation, 
it would be altogether insufficient. With respect to its subserviency 
to lactation, how totally insufficient would it be for a healthy, or even 
a very feeble infant ! The fourth I must protest against, as a fact ; for, 
in all good faith, I avow, that in more than forty year's practice, I 
have never witnessed an unquestionable case of this kind. And, as 
regards the fifth, the daily experience of almost every practitioner 
must be set in opposition to it ; for, though we very frequently employ 
stimulants for the restoration of the menstruous secretion, yet they do 
not act by filling the blood vessels, but by increasing their activity ; 
but are we not obliged, almost always, to employ depleting remedies 
before we can advantageously use tonics ? and do they not sometimes 
succeed without the agency of stimulants ? 

146. The doctrine of fermentation of the chemist ; the mechanical 
solution of Dr. Friend ; the preposterously indelicate hypothesis of Le 
Cat and Brown, do not deserve an attempt at refutation ; we shall 
consign them, with some others, to " the tomb of all the Capulets," 
from whence, we trust, they will never be recalled. 

* Dr. Burdach, a German writer, ill a work entitled " Physiology as an Expe- 
rimental Science," considers menstruation as depending upon causes either general or 
local. "Its general cause," he says, "is evidently to be found in the circumstance of 
the blood being so abundantly generated by the female system, as to produce, every 
four weeks, an excess, which requires to be in this manner evacuated." To prove this, 
he has but renewed the old doctrine of Galen, just noticed, and at once assumes a prin- 
ciple which remains to be proved ; namely, that the female system generates a super- 
fluous quantity of blood, and requires to be removed from the system by an office of 
the uterus. We deny that any satisfactory proof has yet been offered in support of 
this assertion, and for the reasons assigned above ; for Dr. B. only employs the argu- 
ment, just mentioned to sustain this hypothesis, and which we think, are readily 
disproved. 

Dr. B. accounts for this tendency to plethora in the female, by referring it to "a 
greater activity of the productive powers generally, and consequently of sanguification 
existing in the female than in the male system ; for the extent of the menstrual dis- 
charge has an immediate relation with the activity of the productive powers." This 
we uterly deny, as we have known many very plethoric females who have had sparing 
menses, and many that laboured under even a suppression of them ; while as we have 
already observed, we have seen them abundant in debilitated females. 

6* 



58 TOPICAL CONGESTION. 

147. I cannot, however, dismiss this part of my subject, without 
noticing the highly ingenious explanation of Dr. Cullen, by whom it 
w T as taught with all the force of eloquence, and every charm of fancy ; 
and its plausibility, and speciousness, w r as such as to enlist in its 
defence, almost all the teachers in Europe, and not a few in America. 
It is called the theory of 

Sect. III. — Topical Congestion. 

148. Dr. Cullen supposes that the body is developed pretty much 
in the order of necessity, and the size of the vessels belonging to the 
part : hence the head and superior extremities are first unfolded ; then 
the lower extremities ; and lastly, the uterus. " But," says he, " as 
the vessels of every part, by their distention and growth, increase in 
density and thus give greater resistance to farther growth ; at the same 
time, by the same resistance, they determine the blood in greater 
quantity into parts not yet equally developed. By this means the 
whole system must be successfully and equally evolved. Upon these 
principles, there will be a period in the growth of the body, when 
the vessels of the uterus will be in equilibrium with the other parts of 
the system ; and their constitution may be such, that their distention 
may proceed so far as to open their extremities, terminating in the 
cavity of the uterus, so as to pour out blood there; or it may happen, 
that a certain degree of distention may be sufficient to irritate and in- 
crease the action of the vessels, and thereby produce a hemorrhagic 
effort, w r hich may force the extremities of the vessels, with the same 
effect of pouring out blood."' 

149. In either way he accounts for the first appearance of a flow of 
blood from the uterus of women. In order to this, he does not sup- 
pose any more of a general plethora in the system, than what is con- 
stantly necessary for the successive evolution of the several parts of it ; 
and proceeds upon the supposition, that the evolution of each par- 
ticular part must necessarily depend upon plethora, or increased con- 
gestion in its proper vessels. Thus he supposes it to happen with re- 
spect to the uterus ; but as, its plethoric state produces an evacuation 
of blood from its vessels — this evacuation must empty these vessels 
more especially, and put them again into a relaxed state with respect to 
the system. This empty and relaxed state of the vessels of the uterus 
will give rise to a new congestion, till they are brought again to that 
degree of distention, that may either force their extremities, or produce 
a new hemorrhagic effort that may have the same effect. Thus, an eva- 
cuation of blood from the uterus, being once begun by the causes just 
mentioned, it must, by the operation of the same causes, return after a 
certain period, and must continue to do so till particular circumstances 
occasion a considerable change in the constitution of the uterus. What 
determines the period to nearly a month, he cannot explain; but supposes 
it to depend upon a certain balance between the vessels of the uterus 
and those of other parts of the body. This must determine the first pe- 



TOPICAL CONGESTION. 59 

riods; and when it does so, it can be understood, that a considerable 
increase or diminution of the quantity of blood in the whole system 
will have but little effect in increasing or diminishing the quantity distri- 
buted to the uterus. And when this evacuation has been repeated 
for some time at regular periods, it may be supposed that the power of 
habit j which so readily takes place in the animal system, may have 
a great share in determining the periodical motion of the uterus. 

150. Upon this celebrated hypothesis, I shall beg leave to ob- 
serve, first that he has admitted more causes than are necessary to 
account for the phenomena — thus, at one moment, "their distention" 
is such " as to open their extremities, terminating in the cavity of the 
uterus, so as to pour out blood there ; in an instant after, he conjec- 
tures, " that a certain degree of distention may be sufficient to irritate 
and increase the action of the vessels, and thereby produce a hemor- 
rhagic effort, which may force the extremities of the vessels, with the 
same effect of pouring out blood." Here two distinct causes are as- 
signed ; namely, " distention," and a "hemorrhagic effort," for the 
same effect ; — both of these could not possibly operate at the same 
time, if tluey be distinct agents; and if they be not, we are certainly 
entitled to be informed, in what they differ ; for we cannot understand 
what is meant by a hemorrhagic effort, if it be distinct from such a 
degree of distention, as shall force the vessels to yield blood. 2d. 
That if this scheme be true, the menstruous discharge is nothing but 
a common hemorrhage ; for here are vessels distended to such a de- 
gree as to oblige " their extremities terminating in the uterus, to 
pour out blood there." Now, what are we to understand, in this in- 
stance, of blood being poured into the cavity of the uterus, different 
from blood being poured into the cells of the lungs, or the cavity of 
the stomach, when the sides or extremities of their vessels are so 
forced as to yield their contents ? We see none ; yet the appearance 
of the menstruous blood is entirely different from hemorrhagic blood. 

151. Third. Were this doctrine true, no woman could possibly 
preserve the fruit of her womb to the full period of utero-gestation ; 
for it is a fact, as well ascertained as any connected with our history, 
that, so soon as conception takes place, an increased flow of blood to 
the uterus takes place : now, if upon common occasions, much less 
blood will produce such a " distention, or hemorrhagic effort" in the 
vessels terminating in the ?avity of the uterus, that they shall pour out 
blood there, what is there to prevent an increased quantity, the con- 
sequence of pregnancy, from doing the same, and thus deluging at 
once the delicate and unsettled ovum ? 

152. Fourth. It would seem in some measure essential to this 
hypothesis, that "habit" should exert a certain influence, to ensure 
the periodical returns of the catamenia — it can, we think, in one mo- 
ment, be shown that ''habit " has not the smallest agency in the pro- 
duction of this discharge ; for it is notorious to every body, that this 
is constantly interrupted in married women for many months together 
— nine months of pregnancy, twelve or even eighteen months of suck- 



60 FINAL CAUSE. 

ling ; during the whole of which time, the menses do not make their 
appearance ; yet the child is no sooner taken from the breast, than 
this evacuation establishes itself, and with as much regularity as if it 
had never been interrupted. Since then, in these instances, " habit" 
has had no influence upon the first return, it cannot possibly be 
necessary to any number of returns. 

153. From what has just been said it appears that hitherto nothing 
satisfactory has been advanced upon this curious subject — it yet re- 
mains for some future Haller or Hunter to enrich medical science 
with a rational explanation of it. 

Sect. IV. — Final Cause. 

154. The final cause of the menses is perhaps enveloped in some 
obscurity ; but of this we know at least one incontrovertible fact ; 
namely, that the healthy performance of this function is in some way 
or other connected with the capacity for impregnation ; as no well- 
attested instance is upon record, where this has taken place in a fe- 
male who never had had this discharge, or even when it was not of a 
healthy character, and with a greater or less degree of regularity. It 
may perhaps be said, that in the instances of women who had never 
menstruated, there was some imperfection in the genital organs ; and 
this perhaps was the case pretty uniformly. I know it was so in one, 
which fell under my own notice — a young lady of twenty-eight years 
of age had never menstruated, or given any evidence of the necessity 
of this evacuation, as she very uniformly enjoyed good health and 
spirits. She was however, seized with an inflammation of her bowels, 
and soon became alarmingly ill ; I was requested to visit her in con- 
sultation ; and as she never had menstruated, and as she suffered 
severe periodical pains in the region of the uterus it was supposed 
that some derangement of this organ might be the cause of her pre- 
sent suffering ; I was accordingly requested to examine her per vagi- 
nam. The finger passed into the vagina with some difficulty, but the 
uterus was readily touched. It presented to the finger a size not ex- 
ceeding the thumb of a man ; and its neck was as slender as a com- 
mon writing quill, and about half an inch in length. The pubes were 
covered with the usual quantity of hair, and the mammae were pretty 
well developed — the imperfection in this case consisted, most proba- 
bly, in the want of size of the uterus alone ; as it is more than 
probable, from the state of the breasts, and covering of the pubes, that 
the ovaria were not in fault — moreover, she was fond of mixed society ; 
and, I have reason to believe, she was ardently attached to a gentle- 
man but refused to marry, on account of the absence of the menses* 
She died two or three days after the examination ; but leave could 
not be obtained to inspect the body.* 

* Since this time, I have been consulted on a similar case, as far as regards the 
general condition of the female. She is twenty-four years of age; rather tall, and ap- 
parently enjoying a healthy conformation* She has never felt any pain or other incon- 



FINAL CAUSE. 61 

155. M. Renaudin gives an account of a woman in whom the 
uterus was wanting, The subject died of a disease of the stomach ; 
had never menstruated ; was of small stature, only three and a half 
feet high ; imperfect in intellect ; breasts not developed. The exter- 
nal genital organs were well formed ; the hymen in part existed ; and 
a finger introduced into the vagina encountered, instead of the neck 
of the uterus a small tubercle. Between the bladder and rectum, in- 
stead of the uterus, there was a kind of firm cord about the size of a 
quill, communicating at one extremity with the vagina, and also with 
the Fallopian tubes. These tubes were very large, and formed a kind 
of sac, where they opened into the vagina. Some traces of ovaria 
were faintly observable. The vagina perfect ; the neck of the uterus 
imperfectly formed ; the body and fundus altogether wanting. Thus, 
we see that the want of a uterus is by no means unique:* but to ren- 
der such accounts interesting, the previous history of the subject 
should be pretty well known. The case just recorded is valuable, 
because we are informed of the smallness of the body ; the absence 
of certain functional processes ; and the want of development of 
certain parts connected with the genital system, together with the 
weakness of the intellectual faculties ; and it w T ould be curious to 
compare the general developments of the body and mind with the 
absence of the principal genital organs. (See Archives Generales.) 

156. But cases like those just related cannot invalidate the other 
part of the position ; namely, that women must not only menstruate, 
but must menstruate healthily and regularly, to ensure impregnation. 
Besides, a strong analogy is presented to us in the economy of brutes 
— the females of which have their periods of salacity ; at this time 
they have a copious discharge from the vagina, which without ques- 
tion, is of a similar import with the menses of the human female — it 
is not a mere increased flow of the natural vaginal discharge ; for we 
see it instantly detected by the discriminating olfactories of the male. 

157. It maybe asked, why are the menses in the human female 
coloured ? It may be difficult to answer this question satisfactorily ; 
but I am of opinion that one of its uses is to advertise the female, 
when this discharge is arrested, that impregnation has most probably 
taken place ; and thus enable her to make the necessary arrangements 
for the period of becoming a mother. Were this discharge not co- 
loured, it might readily be mistaken for an increase of the secretion 
natural to the uterus and vagina ; but being coloured, this error could 
not well take place. 

venience that would give rise to the opinion, that this absence of the menses was owing 
to an occlusion of the vagina. She is frequently attacked with severe pain in the re- 
gion of the spleen, which will last for several days together. She also suffers greatly 
from headach, palpitation of the heart, and other nervous symptoms. The mammce, 
her mother informs me, are well developed, and the pubes furnished with capilli. She has 
had several eligible offers of marriage ; all of which she has rejected, from an opinion 
that it would be dishonest to marry under such circumstances. I was of opinion that 
there was nothing to be done in her case, and therefore did not prescribe. 

* Licutaud also mentions a case in which it was altogether wanting in a woman he 
dissected. Coitus erat difficilis. 



62 OF CONCEPTION. 



CHAPTER V. 



158. The ingenuity of physiologists has invented hundreds of hy- 
potheses to account for impregnation in the human subject. The 
views of the supporters of these various notions may, however, be re- 
duced to a few general heads : — 1st. They may be divided into those 
who suppose the male semen to be directly conveyed to the ovaries, 
by being urged by the powers of the male apparatus through the neck 
of the uterus, into its cavity ; and from thence to be transported by 
some inherent power of the uterus to these bodies. 2d. Into those 
who supposed this ground not tenable ; and who declared the semen 
is first absorbed from the vagina and carried, eventually, to the ova- 
ries, through the medium of the circulation. 3d. Into those who 
believe the semen makes an impression upon the labia, vagina, or the 
uterus ; and that impregnation takes place by the ovaria sympathizing 
with this impression. 4th. Into those who believe in the direct con- 
veyance of the semen, after its being taken up from the labia pudendi 
or vagina by a set of vessels, whose whole duty it is to convey it to 
the ovaries. 

159. Against the first opinion it may be urged, that many well-at- 
tested instances have occurred, where it was impossible that the ex- 
tremity of the male urethra could be placed in direct apposition to 
the os tincse, so to receive the male semen from it by a vis a tergo, (a 
sine qua non to this hypothesis,) 1st. Because of the entire occlusion 
in some instances, of the os externum, by a too dense hymen, cica- 
trices, or the vagina terminating in the rectum ; consequently, the pe- 
nis could not enter it ; yet impregnation has taken place under such 
conformations.! 2d. By the male urethra not terminating at the ex- 

* We employ this term to signify, the successful application of the male semen to 
whatever is furnished by the female, for the continuation, or propagation of the species. 
Velpeau makes "the function of reproduction of the human species" consist, 1 . Of 
generation, or the formation of the germ ; 2. Of fecundation, or the vivification of the 
germ; 3. Of conception* or the retention of the vivified germ; 4. Of gestation or 
pregnancy ; 5. Of parturition, or the expulsion of the ovum. 

t The celebrated Louis mentions the case of a congenital imperfection of the exter- 
nal organs of generation in a certain young lady who menstruated per annum. She 
was demanded in marriage by a young man to whom she was attached. After much 
resistance, she confessed to him the secret. In the delirium of his passion, he suppli- 
cated her to consent to their union in the only practicable way; to which she consent- 
ed ; became pregnant, and was delivered of a well formed child per annum. 

Louis made this the subject of a ihesis ; for which he was prosecuted by the par- 
liament of France; and the doctors of the Sorbonne interdicted him for addressing to 

* Velpeau defines conception to be that change which takes place between the instant of vivification 
and the period at which the germ shows evidence of development. 



OF CONCEPTION. 



63 



tremity of the glans penis, but beneath it, at the posterior extremity 
of the franum : by the urethra being obstructed by strictures ; by that 
canal terminating at the junction of the scrotum with the body of the 
penis ; consequently, destroying the impetus the semen derived from 
the ejaculatory powers of the male organs, &c. We are aware, that 
it is objected to the cases just referred to, that they happened at a 
period in which much was taken for granted — or, at least, when the 
necessary attention was not paid to anatomical detail. To do away 
widi these objections, we insert two cases most amply in point, that 
fell under the notice of Professor F. Rossi. (See Lancet, vol. i. p. 
385.) 

160. To the second it may be objected, that if the semen were 
absorbed by the lymphatics of the vagina, it w r ould, like every other 
substance subjected to their influence, be changed; consequently, 
could not impregnate an ovum, as it is no longer pure semen. To 
this, it is true, it may be answered, that the very changes imposed 
upon the semen by the absorbents, may be essential to fecundation. 
But this would be flying in the face of the experiments of Spallanzini, 
who found that the semen itself was absolutely necessary to impreg- 
nation. 

161. To the third we may say, it makes no provision for the for- 
mation of mules; for the peculiarities of, and likeness to parents; and 
for the propagation of the predisposition to disease, from parent to 
child ; for the production of mulattoes, &c. 

162. The fourth we must leave to others to object to — I, many 
years since, promulgated this conjecture ; and it has since been in 
part confirmed by the discovery of ducts leading from the ovary to 
the vagina, in the cow and sow, by Dr. Gartner of Copenhagen. 
This seems to be the most simple mode nature could adopt for the 
completion of her favourite object; but, I confess, it wants farther 
confirmation ; and this I sincerely hope, is reserved to reward the 
industry of some American searcher into the minute anatomy of the 
human frame. I cannot but lament here the early death of the inde- 
fatigable and amiable Lawrence, who had intended to have made the 
search for these vessels one of his early occupations ; and from talents 
and industry like his, what might we not have hoped for? 

163. Modern pathological researches, have lately added a new 
species of impregnation to those of the uterine, ventral, ovarian, and 
tubal ; to which the name of " Gravidatis in uteri substantia, or inter- 
stitial pregnancy, " has been given. 

the casuists the following question : " In uxure sic disposita, uti fas sit, vol non ju- 
dicant theoloori morales ?" 

The pope however, more philosophical than the pirliament, or the Sorbonne doctors, 
gave absolution to Mons. Louis ; and his thesis was published in 1754. — Analysis of 
the article of "Extraordinary Cases" in the Diet, des Scien. Med. by Mons. Fournier. 



64 OF THE CHANGES PRODUCED BY CONCEPTION. 



Sect. I. — Graviditas in Uteri Substantia, or Graviditas Inter- 

stitialis. 

164. Dr. Breschet, an eminent physician of Paris, read a paper on 
the subject before the French Academy of Sciences ; which has been 
reported on by the celebrated GeofFroy St. Hiliare ; who has ventured 
an hypothesis on the manner in which this accident occurs, drawn 
from analogical observations made on oviparous animals. We have no 
room for the insertion of these views; a notice of which may be seen 
in the Medico-Chirurgical Review, for October, 1826. The follow- 
ing is a summary, presented in the Bibliotheque Medicale, of the 
cases hitherto recorded. 

165. A case published, in 1801, by Schmidt, in the sixth week of 

gestation. 
1811, by Albers, at two months and a 

half. 
1817, by Henderich, at three months. 
1821, by Henderich, at eight months. 
1823, by Bellemain, at three months. 
1825, by Dance, at three months. 
1825, by Moulin, at two months and a 

half. 
1825, by Auvity, at one month. 

166. Messrs. Moreau and Gurdien report a strange conformation 
of the uterus. "This uterus was well made, with the exception of 
its having a canal on the right Fallopian tube enclosed in the uterine 
parietes, and opening in the neck oi this organ. This vicious con- 
formation may explain the cases which have been witnessed of the 
development of the ovum in the uterine tissue." (Revue Med. Vol. 
I. p. 507.) 



CHAPTER VI. 



OF THE CHANGES PRODUCED BY CONCEPTION. 

167. However philosphers may differ, as regards the mode of ap- 
plication of the male semen to the female ovary, they all agree that 
it is either directly or indirectly essential to impregnation. I shall 
now consider the changes produced upon the female organs after this 
event has taken place ; and shall begin with those induced in the 
ovarium. After successful coition, an ovum is perceived to increase 
in size, and is seen to stand in more decided relief than before from 
the surface of the ovarium ; and it is said, that this body now becomes 



OF THE CHANGES PRODUCED BY CONCEPTION. 65 

more vascular. Arrangements are made, soon after, by the good of- 
fices cS the absorbents for its liberation from its nidus ;* accordingly, 
it becomes exposed, by its peritoneal covering being destroyed by 
these vessels ; and it is now ready to be embraced by the fimbriated 
extremity of a Fallopian tube, to be conveyed through its cavity, to 
the uterus. 

168. The tube, at this time, is found in strict union with the 
ovarium ; and is, in a short time more, found possessed of this little 
sphere. How it is detached from its bed, is not precisely under- 
stood ; some say it falls into the cavity of the tube — others that it is 
mechanically forced into it, by the firm grasp of the tubal extremity, 
£cc. : certain it is, it rarely fails getting into this canal, and made to 
travel by some power or other, its whole length ; it is probably ar- 
rested at the uterine extremity for a short time after it arrives there, 
before it can effect a lodgment within the cavity of the womb. 

169. Physiologists have not settled the point of time, at which the 
ovum loses its connexion with the ovarium ; nor the period it em- 
ploys in travelling to the uterus, or when it is admitted within its 
walls : analogy has furnished almost the only data that even conjec- 
ture can rest upon; and in summoning up the evidence it affords, it 
would seem to be about twenty days. A difficulty, however, has al- 
ways presented itself to get the ovum into the cavity of the uterus 
after it has arrived at the extremity of the Fallopian tube. For it 
would seem, from the acknowledgments of almost all who have in- 
vestigated this point in the human subject, that the Fallopian tube is 
sealed by the decidua passing over it; and that, consequently the 
ovum must be placed behind it : the question then is, how does it 
overcome the difficulty, that this production offers to its immediate 
entrance into the cavity of the uterus ? Before we attempt a solution 
of this question, it will be necessary to inquire, what this production 
is : how it is disposed of; and what are its uses. 

170. It would appear, from the observations of those whose op- 
portunities have led them to the investigation of this obscure part of 
human physiology, that the following fact constantly presents itself; 
that so soon as impregnation takes place, and is perceived, if it maybe 
so expressed, by the ovarium, the internal surface of the uterus throws 
out a vascular tissue,! through its whole extent, which from its being 

* Dr. Blundcll makes the escape of the ovom from its nidus, a morbid or anor.ml 

make3 its liberation depend upon ulceration. Now, we cannot for a moment 

'.hat a process, so essential to tiie fulfilment of the design of man's existence, 

namely, to increase and multiply, can be performed by a pathological condition in an 

for, that ulceration may take place, it must be preceded by inflammation, and 

that of tbe portion of the peritoneum that covers the ovarium; we all know too well 

what would follow from such a condition of this membrane, to suppose it can be in this 

pathological condition for the purpose spoken of. 

t Dr 9 j! irts, after a careful examination of thirty-one healthy uteri, that 

the decidua vera is not a new product, but only a well developed and highly vas- 
cular condition of the lining membrahe of the uterus; which acquires, when in a 
healthy state, a thickness of a line, or even a line and a half, in a state of disease, or, 
in aborted ova, becomes even thicker. — Med. Cfiir. Rev. Loud, for 1633. 

7 



66 OF THE CHANGES PRODUCED BY CONCEPTION. 

after a time cast off, has received the name of membrana decidua : 
this was first accurately described by the late Dr. William Hunter. 
It is, I believe, well ascertained, that all that is necessary to induce 
the uterus to set about secreting this coat, is, that a vesicle be im- 
pregnated. And whether this escape from the ovarium or not, or tar- 
ries in the Fallopian tube, or loses itself in the cavity of the abdomen, 
it never fails to produce the decidua, and that very quickly. Some 
(Dr. Hunter, Scarpa, &c.) have thought it to be a coagulable lymph, 
which soon became organized, by thousands of vessels shooting up 
through the whole extent of its surface ; others (Haller and others,) 
imagined it w r as a kind of continuation of the proper vessels of the 
uterus ; and Mr. John Hunter believed it to be originally a coagulum 
of blood. Injections prove it to be highly vascular ; and constant 
observation declares it to be deciduous ; therefore it must be a tem- 
porary product ; and certainly subservient to the uses of the em- 
bryo. 

171. It is spread over the whole of the internal surface of the body 
and fundus of the uterus, but does not dip into its neck* — it forms, 
as it were, a bag within the uterus ; sometimes we are told (Burns, p. 
193,) it does not stretch across the aperture formed by the neck ; and 
sometimes, (Sir E. Home, Phil. Trans.) it is said not to be continued 
over the mouths of the Fallopian tubes. Mr. Burns formerly, and 
Velpeau more recently, suppose that the decidua entered the mouths 
of the Fallopian tubes ; but it must be evident, at first sight, that 
this arrangement would only unnecessarily obstruct the passage of 
the ovum through these bodies to the uterus. See Essays on various 
Subjects connected with Midwifery, by theAuthor, p. 62. 

172. The uses of this new product cannot be mistaken : it cer- 
tainly serves as a bond of union between the ovum and the uterus ; 
and has, moreover, an indirect agency in the circulation between the 
mother and child. 

173. It is described by Dr. Hunter, Dr» Hamilton, Mr. Burns, and 
others, as a double membrane ; but as Mr. Burns is the latest of these 
authors, as he is extensively engaged in midwifery, and has, as he 
declares, had several opportunities of examining the uterus within 

If any reliance can be placed upon the observation of Cassan, (Reserch. sur le cas 
d'TJterus double, &c.,) this statement of Seiler may be questioned. Cassan slates, that 
in a case of double uterus, one was impregnated, while the other was lined by a closed 
bag of an organized deciduous membrane. 

* Velpeau declares the contrary of this, by saying, it is always found, in " the 
upper part of the cervix in the shape of Solid concrete cords ; and naturally it has no 
opening." We think this account is father obscure ; and we are uncertain as regards 
the real meaning of the author; His expression is, (after stating it, sometimes insin- 
uates itself in the origin of the Fallopian tubes,) **et tourjours dans la partie supe- 
rieure ducol, so us !a forme de cordons, pleiiis,'et contrvtes." We have used Dr. Meigs' 
translation of these words, (" cordons, pleins, et concretes^") because we could not ren- 
der them differently — yet we are at a loss fdr the idea intended to be conveyed, as we 
have never observed, any " solid concrete cords,'' 1 in the many ova we have examined. 
The neck of the uterus is pretty constantly filled by a pretty dense coagulum, which 
has some resemblance to a " cord;" but this is not the same product as the decidua ; 
or, when present in the neck, it is always below the decidtla. 



OF THE CHANGES PRODUCED BY CONCEPTION. 67 

a month after conception ; and, above all, as he is the present autho- 
rity for almost every thing relative to this subject, I shall give his ac- 
count of the mode in which the ovum places itself behind the deci- 
dua, that it may finally descend into the cavity of the uterus. He 
says, " when the embryo passes down through the tube, it is stopped 
when it reaches the uterus, by the inner layer (of the decidua) which 
goes across the aperture of the tube, and thus would be prevented 
from falling into the cavity of the uterus, even were it quite loose 
and unattached. By the growth of the embryo, and the enlargement 
of the membranes, this membrane is distended and made to encroach 
upon the cavity of the uterus, or, more correctly speaking, it grows 
with the ovum. This distention or growth gradually increases, until 
at last the whole of the cavity of the uterus is filled up, and the pro- 
truded portion of the inner layer of the decidua comes in contact with 
that portion of itself which remains attached to the outer layer. We 
find, then, that the inner layer is turned down and covers the chorion : 
from which circumstance, it has been called the decidua reilexa."* 

174. From this statement it would appear, — 1st. That the decidua 
is a double membrane and capable of separation. 2d. That, in order 
that the ovum shall be placed behind the inner layer, it must pass 

* Velpeau* describes this process differently, and we think by no means so satisfac- 
torily, bating the error of Mr. Barns, that the decidua is a doable membrane. lie says, 
" The ovule, after passing- through the tube, necessarily depresses the caducous mem- 
brane, so that it may glide on betwixt it and the uterus, 1o the internal surface of which 
it at last attaches itself: from this moment the pre-existing- membrane is composed of 
two portions; one very large, lining the whole interior of the womb, except the part 
which is in contact with the germ, bears the name of uterine or external caduca ; the 
other very small, depressed by the lower half of the fecundated vesicle, which it enve- 
lops, constitutes the reflected caduca, internal caduca r or epichorion. The extent of 
the former augments in the same ratio with that of ihe womb, and the aggrandizement 
of the latter necessarily follows the growth of the germ." We have three objections, 
principally, to this arrangement. First, it speaks of the ovule gliding betwixt the de- 
ciduaa nd the uterus. Now, this cannot be; for, agreeably to this scheme, whatever 
progress the "ovule" may make within the cavity of the uterus, can only be a me- 
chanical force separating the decidua from the uterus ; for Velpeau admits, that this 
Tnembrane is very large, and lines the whole cavity of the uterus ; conseqnently, before 
the ovule can "glide" betwixt it and the uterus, the decidua must be mechanically de- 
tached from the uterine surface — a work at least of supererogation, if not of violence. 
Now, Mr. Burns describes a more simple mechanism for this obscure process, by sup- 
posing the ovum to carry along with it, that portion of the decidua that is immediately 
before it; and which increases, pari passu, with the ovule itself, and eventually be- 
comes reflected, by turning down upon itself. Secondly, it makes the ovule attach it- 
self to the internal face of the uterus, and this without the intervention of the decidua, 
which cannot be — for, were this true, there would be no necessity for this production ; 
since, agreeably to this plan, it docs not become ihe bond of union between the ovum 
and the uterus. Thirdly, this account leaves out of view the offices of the chorion ; 
for the •« reflected caduca, internal caduca, or epichorion," do not represent the beauti- 
ful product this membrane furnishes, and which is essential to the union of the ovum 
with the deciduous efflorescence, that it may profit by a connexion with the system of 
the mother; but of this, no mention is made. In a word, nothing can be more ob- 
scure than the whole history of the human ovum as given by Velpeau — but this is not 
the place to point out its discrepancies. Agreeably to this scheme, we should have a 
hemorrhagy of greater or less extent during the time the ovum is setting itself within 
the uterus. 

* Elementary Treatise of Midwifery, translated by Dr. Meigg. 



68 THE MEMBRANES. 

through the outer layer ; or, in other words, the outer layer must be 
pierced at either Fallopian tube. 3d. That the inner coat of the 
decidua, \\ 7 hen pressed upon by the ovum, must increase in propor- 
tion to the augmentation of that body, that it may come " in contact 
with that portion of itself which remains attached to the outer layer" 
or, in other words, to become reflected. 

175. If this arrangement be admitted, it must necessarily follow, 
that the ovum will possess three layers of decidua instead of two ; one 
more than has ever been detected, or ever insisted on. I have ex- 
amined many ova, for the purpose of understanding their mechanism ; 
and this with all the care, and all the little ability I have for minute 
dissection, and I can most safely add, without any previously con- 
ceived theory ; yet I have never been able to find but two lamina? of 
decidua.. If Mr. Burns' account were true, where is, or what be- 
comes of the third layer ? and that it must have three, agreeably to 
this scheme, is evident ; viz.. two original layers, and an acquired one 
by reflection, by the increase of the ovum, as it pushes itself forward 
to, " come in contact with that portion of itself which remains attached 
to. the outer layer," " with which it grows." 

176. It will farther follow from these premises: (173, &c.,) I. 
That the process in question, as explained by Mr. Burns, is not 
exactly as he has stated it to be ; or that, 2. The reflected portion 
must be absorbed, as quickly almost as formed ; since it has never 
been observed. As regards ourselves, we confess that we have but 
little confidence in the history of the ovum as given by Mr. B* ; and 
for this plain and simple reason — it does not comport w T ith anatomical 
facts; a foundation upon which the whole must rest, to be satisfac- 
tory. 

177. I have no faith in the statement, that the decidua is a double 
membrane ; at least I have never seen it such ; and of course, until I 
do, I shall admit it with, great caution ; especially as it does not appear 
necessary to the explanation of the process under consideration. 1st. 
Because a work of supererogation would be performed in making tw T o 
layers, when one appears to be all that is necessary; and 2. Because, 
if we believe it to be a single membrane the explanation is easy ; and 
in entire conformity with the anatomy of the ovum, as presented to us 
by dissection. My opinion upon this subject, then, is easily ex- 
pressed, by substituting a single membrane for a double one. To 
understand the union which now T takes place between the ovum and 
this adventitious, covering, it is necessary to say a few: words on. the 
subject of 

Sect. I. — The Membranes,.. 

178. Reasoning on the subject, I was of opinion, that the ovum 
brought its membranes with, it from, the ovarium ; and I am now T alto- 
gether convinced, by the late observations of Sir Everard Home, as- 
sisted by the skill of Mr. Baur, who detected them at a very early 



THE MEMBRANES. by 

period of conception, by the aid of powerful glasses. These mem- 
branes are two in number : the inner one is called the amnion ; and 
the outer one the chorion : they serve to enclose the embryon and the 
water in which it floats, even while it sojourns in the ovarium. After 
the escape of the ovum from thence, these membranes serve two other 
important ends: one is, to furnish by means of the amnion a quantity 
of fluid for the protection of the very tender molecule within ; and 
the other by changes which take place in the surface of the chorion, 
to connect it with the internal face of the uterus. 

179. At first these membranes are not in immediate contact with 
each other;* having between them, a jelly-like substance, which fills 
up the space that separates them : after awhile, however, owing to the 
increase of growth of the amnion, and a diminution of the gluten, 
they approximate each other so nearly, that they may be said to touch. 
The amnion is thin, transparent, and smooth, and it sometimes is des- 
titute of vessels, at least, they cannot be detected by the naked eye : it 
lines or lies below the chorion ; spreads itself over the placenta ; and 
invests the umbilical cord to the umbilicus — here it stops. 

180. The chorion is also a thin, pretty transparent membrane ; and 
is, at the full period of gestation, oftentimes sufficiently strong to resist 
for a long time the impulses of labour, — -indeed, so strong, as very 
much to retard the progess of that process. (See par. 1011.) The 
precise anatomical structure of this membrane, is not perhaps altoge- 
ther well understood at this moment — therefore much has been left to 
conjecture, as regards its more intimate composition. Some have 
assigned lymphatics, nerves, lymphatic exhalents, and inhalents, but 
we believe without sufficient authority. Indeed, it would seem that 
Velpeau (Dr. Meig's translation, p. 159.) calls in question the exist- 
ence of the lymphatic exhalents and inhalents altogether, in the com- 
position of any part of the animal structure ; which, if admitted, would 
very much embarrass the doctrines of the physiological school, whether 
the human body be viewed in a normal or pathological condition. He 
says, " these last two mentioned kind of vessels having been admitted 
in animal bodies, upon the sayso of the physiologists, especially Bichat, 
who never saw thern^ it is good philosophy to reject their existence* 
without discussion, until they shall have been demonstrated by more 
conclusive proofs. The same may be said of the lymphatics, which 
the imagination of Schra?gar and some others, seems to me to have 
detected on the chorion. As to nerves, I may say without offence to 
Chaussier, M'M. Ribes, Home, and Baur, that they are no more to be 
found there, than the exhalents and lymphatics." We think, how- 
ever, that this is rather a hasty, and uncandid denunciation ; at least, 
as regards the exhalents, and perhaps the lymphatics ; as a useful pur- 

* Tins circumstance, though admitted by almost all the writers on this fubject, and 
confc-»-edly curious, and almost necessarily important, has never, so far as we recollect 
elicited a conjecture as to the probable intcn'ion of this arrangement. Is it to protect 
the feeble and delicate germ from impulse or shock, at this curly and tender period of 
its existence ? 

7* 



70 THE MEMBRANES. 

pose might be assigned for their existence, if we cannot imagine any 
utility in the presence of nerves in so insulated a membrane. It ad- 
heres very firmly to the placenta, and gives a covering to all its super- 
ficial vessels ; it also accompanies the amnion} along the whole extent 
of the cord. Its outer surface, very quickly after its escape from the 
ovarium is found to assume a cellular appearance, and presently, a 
flocculent one— it is this coat which furnishes from its external surface, 
the innumerable vessels by which it unites itself to the uterus by means 
of the decidua. When this union is effected, an interchange of offices 
takes place between the chorion and- decidua ; they reciprocally permit 
each other's vessels to repose themselves throughout their respective 
extents, by interlocking in such a manner, as to establish a firm union 
between them. The extremities of the vessels of the chorion penetrate 
the interstices offered by the vessels of the decidua ; while those of the 
latter seek refuge in the meshes of the chorion.* The union of the 
chorion with the decidua is so strict, especially after the second month, 
as always to bring it with k, in cases of abortion. 

181. These membranes enclose, besides the embryo and placenta, 
fluid called the liquor amnii— it would seem to be the product of 
the amnion : in this the foetus securely floats from its earliest existence, 
until the last period of utero-gestation. It seems to be but little more 
than water; having but a little gluten, and muriate of soda in it. It 
is sometimes transparent like water ; at other times it is yellow, brown, 
green, &c, and of various consistencies. Sometimes it is much more 
abundant than at others ; from four ounces, to as many pints. The 
use of this fluid- is to give a uniform distention to the uterus — to pro- 
tect the foetus against external injuries: ; and to afford it the most 
gentle and secure medium to repose in. Dr. Denmanf says, it also 
cc procures the most gentle, yet efficacious dilatation of the os uteri, 

* Velpeau denies the vascularity of these filamentous productions : we are far from 
being satisfied that he is correct in making this denial. If we comprehend this author, 
the formation. of the placenta is entirely independent of the decidua and chorion; a 
circumstance, to say the least, that wants proof., He says, " It is generally thought 
that the down that covers the chorion is of a vascular nature; but as early as 1823, I 
ventured to oppose this hypothesis. What proves that the filaments of the chorion are 
not vessels, is this, that they are to be seen before the blood vessels of the cord are re- 
cognisable. Besides, until the sixth week v every Jlock {filament)- is at least as large 
as one of the umbilical vessels ; so that, as there are only three of these, it is difficult 
for them to give birth to the others, which amount to several hundred. Now, we would 
ask any candid person, whether this amounts to more than, a negative proof of what 
he wishes to establish : for it is not essential-, perhaps, to the existence of these filaments, 
that the umbilical vessels be visible, as the chorion may have an independent power to 
form them. Besides, it is not absolutely necessary, for the formation of vessels pro- 
ceeding from it. We have sufficient evidence of this in the division of the carotids, 
&c. Farther, these villosities are regularly spread over the whole of the periphery of 
the ovule, and are independent of each other, while the cord and placenta are only con- 
nected with one point of this vesicle." M. Velpeau seems to forget that this kind of 
arrangement exists in the folly developed placenta; for the cord is inserted but at one 
point of this mass ; and it would puzzle him to show that the whole composition of this 
important organ is not vascular; and that the area of all this immense congeries of 
vessels, does not exceed the area of the vessels constituting the cord. 

t, Introduction, Francis's ed. p. 219. 



THE PLACENTA. 71 

and soft parts at the time of parturition." This opinion I shall have 
occasion to advert to.* 

IS 2. The ovum, after its establishment within the uterus, or after 
it is expelled by violence from it, consists of the decidua, the decidua 
reflexa, chorion, and amnion; of the liquor amnii, the foetus, and um- 
bilical cord ; the latter has one extremity inserted into the umbilicus 
of the child ; the other affixed to the membranes, which now consti- 
tute— 

Sect. II. — The Placenta. 

183. The placenta is that. vascular mass by which the circulation 
is maintained between mother and child ; and by which the latter is 
nourished. Its size is various, owing to the constitution of either 
mother or child, or both — -it resembles in shape a large cake ; it is in 
general nearly circular, thicker in the middle than at the edges. It 
presents two surfaces ; namely, the uterine or maternal surface, and 
the foetal surface. The former presents rather a rough and spongy 
appearance, traversed by several sulci of very inconsiderable depth ; 
it is not unaptly compared in its appearance to the infractuosities of 
the brain ; it is covered by a very fine cellular coat, but of such great 
delicacy, as to break upon the slightest bending of this mass. The 
eminences and sulci observed upon its maternal face, have been sup- 
posed to arise from a kind of necessity, for the greater security of at- 
tachment, by corresponding risings and sinkings on the internal face 
of the uterus. I do not believe in this necessity, and suppose these 
sulci are the mere impressions of the maternal vessels, which are so 
much swelled beyond the plane of the common surface of the uterus, 
as to impress the placenta with furrows like the internal surface of the 
skull, by the vessels of the encephalon. 

184. The internal surface is covered by the chorion and amnion, 
through whose coats may be perceived a beautiful display of vessels ; 
sometimes they are found in fine regular order, like radii from a 
centre ; at others running into fantastic irregularity : these vessels are 
both the arteries and veins which tend to a common point, and when 
united form what is called the umbilical cord : in uniting to form this 
rope, they sometimes run parallel to each other for several inches: 
then twine round each other alternately until they arrive at the umbi- 
licus of the child, f 

what is said, when we speak of the opening of the os- nteri. 
t Velpeau makes the twisted appearance of the cord to depend upon the movements 
of the foetus; he says, "'The reason of this twisted. appearance,, seems to me to be very 
plain : it depends on the rotatory movements of the child in the womb, and ten times 
out of twelve, it turns from left to ri^ht, according to my own and Meckel's observation. 
In some subjects the cord is turned in one direction near the placenta, and in the nppo. 
site one near the child's belly; most frequently it looks like a real rope, and hence, 
derived its name, Cord. Sometimes all three of the vessels turn on an 
ideal axis; at others the vein is tsvisted round the arteries, but in general, the arteries 



72 THE PLACENTA, 

They are connected through their whole extent by a fine cellular 
product, in the interstices of which we constantly find a tenacious, 
ropy fluid. 

185. This cord consists almost always of two arteries and a vein : 
the vein conveying the blood to the foetus, and the arteries conduct- 
ing it from it ; the veins of the placenta rarely have valves ; while 
valves are frequently found in the arteries.* The arteries are con- 
tinuations of the iliacs of the foetus ; they pass out at the umbilicus, 
and run to lose themselves, in the substance of the placenta : they an- 
astomose with each other within the meshes of this mass, as well as 
with some of the venal branches ; this kind of communication is suffi- 
ciently extensive, to enable us to, fill the whole plexus, by injecting 
one of the umbilical arteries ; in like manner may the arteries be filled 
by injecting the vein. The vein originates by many branches in the 
substance of the placenta, and after a variety of unions, collects itself 

are twisted round the vein," p. 7.7. It is. truly surprising that M. Velpeau, should have 
offered such an unphilosophical explanation of the disposition of the umbilical vessels; 
especially as he is so skeptical upon certain physiological points, that are every way 
vastly more probable than the one in, question — for instance, his doubts of the exist- 
ence of serous or lymphatic vessels in the chorion ; lymphatics themselves; blood ves- 
sels as belonging to the same membrane; the vascular nature of the spongy chorion, 
&c. &c. Now as regards the cause of the twist in the umbilical vessels, his explana- 
tion is, we had like to have said, absurd,.. and he himself furnishes arguments enough 
to destroy it, without our having the trouble to furnish more. For instance — he says, 
that "the cord in some subjects is turned in one direction near the belly of the child, 
and in another, near the placenta." Now,, a school-boy would laugh at any one, were 
he directed to ^twist his whip cord in one direction at one end, and in the opposite 
direction at the other,, without some intervening remora; for the little rogue would 
know, that these contrary efforts to twist his string, would instantly destroy each other. 
Again; if the fact be admitted, that the cord is twisted by the gyrations of the child, 
why does not the twist unfold itself when one of its extremities is set at perfect liberty 
by cutting the funis ? — «Did M. Velpeau, or any body else, ever see the umbilical cord 
twirl itself into an opposite direction to the twist, upon becoming detached from the 
child or placenta. Again : were this the true explanation, why is the twist confined 
to the vessels constituting the cord, and the membranes covering them, not implicated 
by the same mechanical movements ? Why are the membranous parts of the cord, 
without the slighest twist, when the vessels run parallel to each other, for some dis- 
tance, nay in some instances, for several inches together, while in the portions both 
above and below, the vessels that surround each other as is ordinary ? Does not the 
fact detailed by M. V. himself, seem to prove, that God has established some law, and 
for some wise purpose, upon this subject? or why should the direction of the vessels be 
"ten times out of twelve,.from left to right?" Were the spiral directions of the ves- 
sels of the cord contingent, why should they not be in equal, or nearly in equal, pro- 
portions to each other ? Why should they be, "ten times out of twelve, from left to 
right ?" Can M. V. give us any explanation of the law that governs the motion of the 
child in this case, and which obliges it to gyrate from right to left, that it may twist 
the cord from left to right? &c. &c. Again ; M. V... informs us immediately after, 
that it would be a mistake to suppose that the umbilical! vessels never separate, because 
they do not generally do so. " Their division may take place at the distance of one, 
two, or four inches from the inner surface of the chorion, and even very near the ab- 
domen of the child." In such cases, what has become of the gyrating influence of the 
child ? — Had this existed, these are the very parts that would have first felt its effects. 
* There are exceptions to the number of vessels that compose the cord. There is, 
in a preparation, in Dr. Blundell's collection, a cord, consisting of a single artery and 
a vein. On the other hand, Blundell and Velpeau, describe a cord consisting of one 
artery and two veins. — Dr. Ryan's Manual, 3d. Ed. p. 72. 



FCSTAL CIRCULATION. 73 

into one trunk, near where the arteries give off branches, the area of 
which is rather more than that of the two arteries. 

1S6. This mass is subject to various affections, some of which, as 
sub-inflammation, dropsical infiltrations, and ossification, appear to be 
destructive to the foetus ; while others, as varicose affections of its 
superficial veins, and ossification of portions of its reticulated sub- 
stance, do not appear to have any influence upon its health. Dr. 
Katerbeau states, that " in the month of February, 1S28, a woman 
was delivered of a healthy female child : she had complained, many 
weeks previous to her confinement, of a pain in the womb, and a 
feeling as if something within it pricked and cut her ; for these sen- 
sations many remedies were administered without effect. After a 
tolerably speedy birth of a child, the placenta did not come away, and 
the mid-wife supposing it to adhere, proceeded to loosen it, which 
was easily done. During the operation the patient complained of 
violent pricking within the uterus." 

\ "Upon inspecting the placenta," the Doctor remarks, "I 
found, throughout its substance, that numerous spicula of bone were 
interspersed, the whole of which resembles the points of ossification 
in a foetal skull : they were firmly united to the integuments of the 
placenta, and in some parts, especially over the insertion of the cord, 
were arranged together so as to present somewhat of an aborescent 
appearance." (Hufeland and Osann's Journal, June, 1828.) 

188. We have seen a number of instances of similar partial ossifi- 
cations of the placenta, but in none of which, did we perceive that 
this condition interfered with its usual economy.* 

Sect. III. — Fcetal Circulation. 

189. There are five striking peculiarities in the sanguiferous sys- 
tem of the foetus: 1st. The vena umbilicalis. 2d. The ductus veno- 

* Mr. Cruveilhier enumerates several different affections of the placenta, which 
perhaps are more curious than useful, as we have no mode before delivery of detecting 
them, and if we had, it is questionable whether we could relieve them. It would, I 
think be subjecting the woman to a severe ordeal without the probability of being of 
the least use to her. 

Mr. Cruveilhier thinks that they may be all comprised under the following 
beads : 

1. Hypertrophy. This sometimes consists in a serous infiltration, analogous to 
what is frequently observed in the umbilical cord. [I have seen many such.] 

Atrophy. This may be general or partial, and confined to some of the cotyledons. 
The consequence may be wasting, or even death to the embryo. 

Inflammation of the placenta. Independently of less decisive marks, the inflamma- 
tory affections of the placenta are proved by the following case. In one the placenta 
was very large, and the quarters of it was covered by a large deposit of purulent 
matter, mixed with blood. 

Ossification of the placenta. Are of two kinds — the one shell-like and friable, the 
other with spieula?. [This I have often seen. J 

rid cysts of the placenta. These are said to be the most common of the morbid 
appearances of the placenta. 

Apoplexy of the placenta. This he thinks is proved by the collection of blood, in the 
substance of the placenta. [This I have often seen without suspecting apoplexy of this 
mass.! 



74 FCETAL CIRCULATION. 

sus. 3d. The foramen ovale. 4. The ductus arteriosus. 5th. The 
arteria? umbilicales. 6th. To these we may add, that the blood 
itself is different from adult blood, in several particulars, agreeably to 
Fourcroy : first, its colouring matter is darker ; it contains no fibrine, 
but, probably, a greater proportion of gelatine, nor does it possess 
phosphoric acid. — firm, de Chirurg. torn. 7. p. 262. 

190. 1. The vena umbilicalis arises by very fine branches in the 
placenta. These branches are collected into one trunk, near the cen- 
tre of the placenta ; which trunk, forming a considerable part of the 
volume of the cord, enters behind the abdomen through the navel pe- 
ritoneum, and running along the anterior margin of the suspensory 
ligament of the liver, empties into the left branch of the sinus of the 
vena portarum. While it is engaged in the anterior section of the 
umbilical fissure of the liver, it gives off several small branches to the 
substance of the liver. Nearly two-thirds of its blood is distributed 
to the liver, through the sinus of the vena portarum and the small 
branches. 

191. 2. The ductus venosus arises from the left branch of the sinus 
of the vena portarum, and empties into the left hepatic vein, near the 
junction of the latter with the ascending vena cava abdominalis. The 
ductus venosus occupies the posterior section of the umbilical fissure, 
being much smaller than the vena umbilicalis, and arising from the 
sinus of the vena portarum, at its back part, directly in face of the 
entrance of the umbilical vein, so that a probe may be passed very 
readily from the one into the other. 

192. 3. The foramen ovale is a large aperture between the two 
auricles of the heart, furnished with a valve on its left side, which is 
shut down the moment after respiration begins. 

193. 4. The ductus arteriosus is a canal leading from the pulmo- 
nary artery into the aorta. It is so large as to appear like a continua- 
tion of the pulmonary artery, and discharges into the aorta at the 
lower part of its curvature, just after the origin of the left subclavian 
artery. The right and left pulmonary arteries, being at this time but 
very small branches, arise on each side of the ductus arteriosus. 

194. 5. The arteriee umbilicales are two in number, being continua- 
tions of the internal iliac arteries, which are here much larger than the 
external iliacs. The arterise umbilicales make a curve, running on 
the lateral parietes of the bladder, converge to the navel, and, passing 
through it, accompany the umbilical vein to the placenta. They twist 
spirally around it, and are distributed by very fine branches to the pla- 
centa, cqmmunicating with the extreme branches of the umbilical 
vein. 

195. The course of the foetal circulation is then, from the placenta 
through the umbilical vein and ductus venosus, into the ascending 
cava, whereby the blood is discharged into the right auricle of the 
heart. The position of the Eustachian valve is such as to turn the 
greater part of this column of blood into the left auricle through the 
foramen ovale. The left auricle may, therefore, be considered as 



OF THE CHANGES WHICH TAKE PLACE, &C. 75 

distended with the blood of the ascending cava, while the right auri- 
cle is distended with the blood of the descending cava. The auricles 
contract at the same time, and fill the ventricles. The ventricles also 
contract together, and fill the pulmonary artery and the aorta. The 
size of the ductus arteriosus enables the right ventricle to discharge 
the greater part of its blood through it into the descending aorta. 
This blood is very impure. The blood passing through the foramen 
ovale to the left side of the heart, by being driven through the root of 
the aorta, is turned off to the head and upper extremities, through the 
arteria innominata, the left carotid and left subclavian ; and what 
remains after this diversion, joins the blood of the ductus arteriosus in 
the descending aorta. A small portion of the blood of the descending 
aorta goes to the lower extremities, but much the greater part circulates 
through the umbilical arteries to the placenta, where, after being vivi- 
fied, it runs into the extreme branches of the umbilical vein, and then 
repeats the same round until respiration begins.* For the most part, 
immediately on respiration occurring, the vena umbilicalis, the ductus 
venosus, the foramen ovale, the ductus arteriosus, and the arteriae 
umbilicales, are closed, not to be again opened unless in very extra- 
ordinary cases. 

Sect. IV. — Of the Changes which take place in the Uterus from 
Impregnation. 

196. Hitherto I have been considering the changes induced upon 
the ovum by impregnation; it is now proper to notice those which 
take place in the parietes of the uterus itself. These changes com- 
mence on the internal surface of the uterus with those on the surface 
of the ovum ; for no sooner is a vesicle fecundated, than the uterus 
has more than its usual quantum of blood sent to it ; and this increases 
with the progress of gestation. The vessels, as already noticed, are 
very small, and very much convoluted before fecundation ; now 
quickly enlarge, and become straighter — and this increase and deve- 
lopment continues until they arrive at a very considerable magnitude; 
so much so, indeed, that some of the largest of these vessels, at the 
full period of utero gestation, are capable of admitting the extremity 
of the little finger. 

197. The fibres of which the uterus is chiefly composed, begin to 
develope themselves, so as to be recognised as muscular ; they assume 
more distinct directions, and though not susceptible perhaps of positive 
demonstration as to course, and form, are yet sufficiently palpable to 
deserve the name of muscular fibres. In consequence of this change, 
these fibres become longer and more lax ; and admit, without restraint, 
the interposing and much enlarged vessels that traverse them in all 

* Dr. Ryan, in his "Manual of Midwifery," p. 142, says, " Dr. Dewees is confused 
on this point ; for he alleges tha* the blood discharged by the umbilical arteries passes 
into the umbilical vein, and is there purified; which cannot happen." Dr. R. has cer 
tainly read the passage marked by italics, without due attention— the reader will 
please to cornoare the above quotation with what I have really said. 



76 OF THE CHANGES WHICH TAKE PLACE, &C. 

directions, until the uterus itself is no longer capable of bearing farther 
distention with safety. 

198. This increase of size is by no means without its laws — on the 
contrary, the most perfect regularity and order are maintained, from 
the beginning to the end of gestation — so uniform is the progress of 
development, that the period of pregnancy can with considerable cer- 
tainty be pointed out by the experienced accoucheur, by ascertaining 
the degree of distention the uterus has undergone, provided it be 
beyond the third month. Until this time, we are of opinion, that it 
would be hardly safe to hazard a positive opinion, especially in such 
cases in which it may be highly important to decide ; and in which a 
decision may involve both life and character. 

199. The position, as well as distention of the uterus, lead us to a 
knowledge of the advancement of pregnancy — for the first three, and 
sometimes at the fourth month, the uterus is found, in consequence of 
its weight, rather lower in the vagina than it usually is when not im- 
pregnated — after the fourth month, or at the end of the fifth, the fundus 
can be felt at the pubic region — at the sixth, half-way between it and 
the umbilicus — at the seventh, at the umbilicus — at the eighth, half- 
way between the umbilicus and the scrobiculus cordis— at the ninth, 
but very little higher, in a well formed pelvis. For at this time, there 
is a subsiding of the uterus within the pelvis, owing to the more fre- 
quently repeated, and stronger contractions of the body and fundus, 
and the now almost complete development of the neck of the uterus. 
It is not, however, the fundus and body alone, that surfer changes 
during the periods just stated ; the neck, after the sixth month, par- 
ticipates in these alterations : it gradually becomes shorter and shorter, 
until after the eighth month ; and, at the ninth, it is entirely obli- 
terated. 

200. The body and fundus first yield to the influence of the ovum ; 
and they continue to expand until about the seventh month, or per- 
haps a little earlier. After this time, they seem to refuse to yield 
farther ; the neck then is obliged to contribute its mite for the farther 
accommodation of the foetus, and its appurtenances, which it does 
until the period of labour commences. At this time no trace of the 
neck is to be found : nothing remains of this pendulous part, but its 
orifice ; which now, may be distinctly observed to be a little open. 

201. The fundus and body of the uterus, not only yield before the 
neck, but some one part contributes more than another to the room 
necessary for the comfort of the foetus ; and these are the posterior por- 
tions — hence, they are found thicker, in the unimpregnated state ; (121) 
and hence the Fallopian tubes are always found, at the last period of 
pregnancy, in advance of the uterus: a fact of much importance in 
performing the Cesarean section. 

202. In proportion to the advancement of pregnancy, the uterus 
acquires a deeper tone of colour : this is owing solely to the augment- 
ed quantity of blood which it now possesses. 

203. The power by which the uterus is distended, has been dis- 



OF THE CHANGES WHICH TAKE PLACE, &C 77 

puted. Dr. Denman will not admit the agency of the ovum ; he says, 
" It is evidently not mechanical from the increasing size of the ovum, 
but from the accession of a new principle ; for the uterus is never fully 
upon the stretch, like a bladder inflated with air, but relaxed in such 
a manner as to be apparently capable of bearing the farther increase 
of the ovum without inconvenience." 

204. We should be at a loss to comprehend this doctrine of Dr. 
Denraan's, were we even to admit his proof. To say the uterus has 
acquired a new principle, does not do away the difficulty of under- 
standing how it acquires size, unless something be positively added 
to this organ, at the time it gains the principle ; for he must admit the 
uterus is enlarged ; yet it is not distended like a bladder filled with 
air ? — In what does the difference consist ? There must be an increase 
of matter, as well as an "accession of a new principle," to prevent 
its being distended like " a bladder filled with air," or it must be 
stretched like one. — If it be declared there is an increase of matter, 
we would ask for the evidence ; as well as inquire what becomes of it, 
immediately after delivery ?* 

205. I am of opinion that, were the bladder circumstanced pre- 
cisely like the uterus, or the uterus like the bladder, the same pheno- 
mena would present themselves ; that is, let the uterus be deprived of 
its adventitious blood, as would happen after severe hemorrhage, and 
it would be found as thin nearly, or perhaps quite, as the bladder, all 
things being equal : or let the muscular fibres of the bladder be sepa- 
rated by as many, and as large vessels as those of the uterus, and it 
would be as thick as the uterus when in a state of distention ; for we 
must deny that the uterine parietes, when freed from all their blood, 
are as thick as they were when unimpregnated. 

206. Dr. Denman denies that the uterus is ever in a state of " full 
distention." I do not know what he would wish us to understand 
by " full distention ;" if he mean, that it is still capable, under extreme 
pressure, of yielding farther, I should agree with him, that it is still 
capable of greater distention ; but if he mean that it is never as much 
distended, as is compatible with either its economy or comfort, at the 
full period of utero-gestation, I would certainly deny, and would seek 
for no other proof, than the well known fact, that, after the seventh 

* I am happy to avail myself of the opinion of the judicious and experienced Dr. 
Ramsbotham, up <n this subject. He says, "that there is no actual deposition of new- 
animal matter within the uterine structure during pregnancy, appears to me evident 
in the established fact, that the uterus, by a process of silent and gradual contraction, 
continued for some time after the expulsion of \U contents, can and docs possess the 
po-\er of daily diminishing its volume, until it has acquired its smallest unimpregnat< d 
size; when it is again able to resume its original and peruli ir func'lons. J3ut if the 
parietes of the gravid uterus be supp-sed to owe their size to bulk, acquired by the de- 
position of new animal matter, by what natural means is that matt< r so sudd- nly re- 
moved 7 Can the effects of absorption be thought equal to it? We see no such rapid 
diminution of size from the powers of the absorbent system under diseased structure. 
Contraction alone explains iC—Pract. Obs. Am. ed. p. 26. 

Dr. Blundcll suggests, that " it is, perhaps, in good measure, in consequence of the 
absorbents being large, numerous, and active, that the uterus, after delivery shrinks so 
rapidly."— Prin. and Pract. of Obstet. p. 79. 
8 



78 OF THE DEVELOPMENT OF THE F02TUS, 

month, it is constantly found resisting farther encroachments, by being 
excited to regular and constant contractions, as may be distinctly per- 
ceived by the introduction of the finger into the os uteri. Besides, 
did we not admit this resistance to farther distention on the part of 
the body and fundus, how shall we ever explain the unfolding of the 
neck of the uterus at the period just indicated? Now, if it be dis- 
tended at the ultimate period of pregnancy, to the point of resistance, 
would it not seem to be a rational and natural deduction, that it had 
proceeded to " full distention, 77 or at least, as far as was compatible 
with its economy, or even with the integrity of its organization ? 

207. We may also urge in favour of the ovum having an agency 
by its growth in the distention of the uterus, that, if the liquor amnii 
be discharged, the uterus will collapse immediately, and accommodate 
its parietes to the form and size of the remaining contents. Could 
this be, did the uterus acquire its additional bulk during pregnancy, 
from an increment of new animal matter ? If this additional matter 
did exist, it would doubtless be of serious mischief in cases of flood- 
ing ; as it must necessarily interrupt contraction. 



CHAPTER VII. 

OF THE DEVELOPMENT OF THE FCETUS. 

208. A strong and certainly a laudable curiosity is almost always 
felt by the student, to ascertain the progress of development of the 
fetus from the moment of its conception, up to the full term of gesta- 
tion. And though our knowledge upon this subject must necessarily 
be both limited and uncertain, yet enough is known to enable us to 
form a tolerably correct estimate of the progress the embryo or fetus 
makes, up to its final development. 

209. The latest information upon this subject will almost necessarily 
be the best ; as all that is known upon this head, must consist of a 
series of histories by different naturalists, anatomists, &c. ; we shall, 
therefore, avail ourselves of the accuracy and industry of Dr. Beck* 
upon this point ; and at the same time, tender that gentleman our 
thanks for this and several other pieces of valuable information con- 
nected with several of our subjects. 

210. Dr. Beck says, "I will premise that the following summary 
is drawn from the observations of Aristotle, Hippocrates, Riolan, 
Haller, Roederer, Meckel, Burton, Baudelocque, William Hunter, 
Burns, Chaussier, Beclard, Capuron, Clarke, Merriman, and Soem- 
mering. 

* Elements of Medical Jurisprudence, vol. I. p. 162. 



OF THE DEVELOPMENT OF THE FCETUS. 79 

211. " From the time of the first evidence of impregnation to the 
fifteenth day, the produce of conception appears only as a gelatinous, 
semitransparent, nocculent mass, of a grayish colour, liquefying 
promptly, and presenting no distinct formation, even by the aid of a 
microscope. At thirty days, it has the size of a large ant, according 
to Aristotle, or of a barley-corn, according to Burton. Baudelocque, 
however, observes, that it is not larger than the malleus of the tym- 
panum. Its length varies from three to five lines. At six or seven 
weeks, its length is almost ten lines. The form and lineaments of 
the principal organs, and the place from which the members are to 
arise, can now be observed, and it is equal in size to a small bee. 
At this time also, the fluid contained in the membranes is much 
heavier than the embryo. At two months, the length is about two 
inches, and its weight nearly two ounces. All the parts are perfectly 
distinct, and many points of ossification are observed in the head, 
trunk and members. Sometimes the male sex maybe distinguished. 
At the third month, it is about three and a half inches long, and 
between two and three ounces in weight. The nose and mouth are 
formed, and the features of the face become more distinct. The eyes 
are shut, and the eyelids adhere together — the head is longer and 
heavier than the rest of the body — the umbilical cord is formed — the 
genitals are distinct — the penis, &c, are relatively very large — the 
nymphae are projecting, and the labia very thick. At the fourth 
month, the foetus is from five to six inches long, and weighs from 
four to five ounces. The external parts all develope themselves, 
with the exception of the hair and nails. The great relative propor- 
tion of the fluid of the membranes disappears, and the fetus nearly 
fills the cavity of the uterus. During the fifth month, the motions of 
the fetus are felt by the mother. The length is from seven to nine 
inches, and the weight nine or ten ounces. The brain is pulpy, and 
is destitute of circumvolutions or furrows. The external ear is com- 
pleted about this time, though its shape, which is like that of a gently 
depressed circle, differs from the ear after birth. 

212. " In the sixth month, we begin to find some trace of fat under 
the integuments, where previously nothing but a mass of gelatine had 
been observed. The head also, which before had been proportion- 
ably large, becomes smaller in comparison with the body. It is now, 
however, large and soft, and the fontanelles are very much expanded. 
The brain acquires more consistence, but is still easily dissolved ; 
and the pia mater seems only to lie over its surface, being separated 
with crcat facility. The skin is very fine, pliant, and thin, and of a 
purple colour, especially in the palms of the hands, the soles of the 
feet, the face, lips, ears, and breasts. In males the scrotum is slightly 
developed and of a bright red colour; and the testicles are still in 
the abdomen. In females the vulva is projecting, and the labia 
separated by the protuberance of the clitoris. The hair on the head 
is very thinly disposed, short, and of a white or silvery colour — the 
eyelids are closed ; the hair on the eyebrows and eyelashes but thinly 



bU OF THE DEVELOPMENT OF THE FCETUS. 

scattered, and the pupil is closed by a membrane. The nails are 
wanting, or scarcely apparent. The lungs are very small, white, and 
compact. The heart is large, and the liver very large, and situated 
near the umbilicus — the gall bladder contains only a small quantity 
of a nearly colourless fluid; and the meconium is small in quantity, 
and is found only in a part of the large intestines. The bladder is 
hard and pyriform, and has a very small cavity. The ordinary weight 
of the foetus, at this time, is from one to two pounds ; and its length 
from nine to twelve inches, the middle of which is at the abdominal 
extremity of the sternum." 

213. "At the seventh month, all the parts, both external and 
internal, are still more developed. The skin assumes a rosy hue, 
and becomes more dense ; and it is covered with a sebaceous fluid, 
so as to form a whitish, unctuous covering. The eyelids are no 
longer united, and the membrane pupillaris separates, so as to form 
the pupil. The cerebral pulp becomes more consistent, and its sur- 
face is a little furrowed, and adheres somewhat to the meninges. 
The meconium increases in quantity — the hair on the head is longer, 
and takes a deeper hue. The nails acquire more firmness. Weight 
from two to three pounds. Length from twelve to fourteen inches- — 
the middle of which is nearer to the sternum than to the navel. 

214. "At the eighth month, the skin has acquired more density, 
and is whiter ; it is covered with very fine white hairs, and its seba- 
ceous covering is more apparent. The nails are firmer ; the hair of 
the head longer, and more coloured. The breasts are often project- 
ing, and a lactiferous fluid may be pressed from them. The testicles 
in males are frequently engaged in the abdominal ring. In females 
the vagina is covered with a transparent mucus. The grooves in 
the cerebral substance gradually become more marked ; the spinal 
marrow, pons variolii, and medulla oblongata, acquire a remarkable 
consistence, and even firmness. The lungs are of a reddish colour ; 
the liver preserves nearly its former relative size, but it is more 
remote from the navel ; the fluid in the gall bladder is of a yellowish 
colour, and has a bitter taste. The weight at this time, is from three 
to four, and sometimes five pounds. Length, sixteen inches or 
more — the middle of which is nearer to the navel than to the sternum. 

215. "At the ninth month, ossification is more complete — the 
head is large, but it has a considerable degree of firmness. The 
bones of the cranium, though moveable, touch each other with their 
membranous margins; the fontanelles are smaller; the hair is 
longer, thicker and of a darker colour; and the nails become more 
solid and prolonged to the extremity of the fingers. The convolu- 
tions on the surface of the brain are more numerous — the cineritious 
portions begin to be distinguished by their colour; and though the 
lobes which compose the cerebrum retain their former softness, yet the 
cerebellum and the basis of the cerebrum, have acquired a remarkable 
consistence. The head measures longitudinally, from the forehead 
to the occiput, four inches, to four inches and a quarter ; and trans- 



OF THE DEVELOPMENT OF THE FCETUS. 81 

versely, from three and a half to four inches. The abdomen is now 
large and round. The lungs are redder and larger. The canalis 
arteriosus is large, and its coats are thicker and denser than formerly. 
The meconium fills nearly the whole of the intestines and the bladder 
contains urine. In fact, the digestive apparatus, the heart, and the 
lungs, are in a state fit to commence extra-uterine life. The length 
varies from nineteen to twenty inches or more — the middle of which 
is at the navel, or a very little below." 

216. The detail of the progress of development just given must, 
however, be looked upon but as a general scheme, to which many 
exceptions will necessarily present themselves, nor can a nearer ap- 
proach be well made : since almost every country will present indivi- 
dual differences; especially in the weights and measurements of the 
embryo and the fetus ; consequently, the estimates here given, must 
not be regarded as rigidly exact. Indeed, our individual experience, 
were it compared with many of these statements, would be at variance 
with them ; but not so extensively as to invalidate the general esti- 
mate. 

217. Nothing, perhaps, will place these observations in a clearer 
light, than giving the standard average weights of the newly born 
foetus in different countries, as has been collected with so much in- 
dustry by Dr. Beck, and whose account we will make use of. 

218. " The weight of the fetus, at the full time of utero-gestation, 
has been the subject of numerous observations ; and, as a preliminary 
remark, it must be noticed, that this differs according to the confor- 
mation and habits of the parent, and the sex of the child. Healthy 
females, residing in the country, or engaged in active occupations, 
have generally the largest children. Male children, also, generally 
weigh more than female ones. 

219. " In Germany, Roederer found the weight, in one hundred 
and thirteen cases, to vary from seven to eight pounds ; and he lays it 
down as a rule, that it is rarely less than six pounds. Dr. Hunter 
states, that Dr. Macauley examined the bodies of several thousand 
new-born and perfect children, at the British lying-in Hospital, and 
found that the weight of the smallest was about four pounds, and the 
largest eleven pounds two ounces; but by far the greatest number was 
from five to eight pounds. Dr. Joseph Clarke's inquiries furnish 
similar results. 

220. " The greatest proportion of both sexes, according to him, 
weighed seven pounds ; yet there were more males than females found 
above, and more females than males below that standard. Thus, out 
of sixty males and sixty females, thirty-two of the former, and twenty- 
five of the latter, weighed seven pounds, and there were fourteen 
females, and only six males, who weighed six pounds. On the other 
hand, there were sixteen males, but only eight females who weighed 
eight pounds. 

221. "Taking, then, the average weight of both sexes, it will be 
found that twelve males are as heavy as thirteen females. The exact 

8* 



82 OF THE DEVELOPMENT OF THE FCETUS. 

average weight of male children, according to Dr. Clarke, was seven 
pounds five ounces and seven drachms ; and that of female, six pounds 
eleven ounces and six drachms.'' 

222. " Dr. Clarke of Dublin r found the weight to vary from four 
to eleven pounds. Dr. Merriman states in his Lectures, that he de- 
livered one that weighed fourteen pounds, (it was born dead,) and 
Dr. Croft delivered one alive, weighing fifteen pounds.* 

223. " In France, the weight seems to be less than in England. 
Of 1554 examined by Camus, the greatest weight was nine pounds ; 
and of this there were sixteen instances ; the ordinary from five to 
seven, and the average, six pounds and about a quarter. There 
were thirty-one instances in which the weight was as low as three 
pounds. Baudelocque, however, states that he saw several instances 
in which the weight was about ten pounds, a few where it was twelve, 
and one of thirteen. Subsequent observations on twenty thousand 
children at PHospice de la Maternite in Paris, have shown a few in- 
stances where it has been one hundred and sixty-eight ounces; that 
is, ten pounds and a half; and this is the highest term. Capuron 
mentions, that he has seen two instances where the children weighed 
twelve pounds. 

224. " We shall, as a deduction from the above observations, be 
probably most correct in allowing the average to vary from five to 
eight pounds. Dr. Willoughbyf informs us, that as far as his obser- 
vations have extended, the average weight of children is upwards of 
seven pounds," p. 167, &c. The result of Dr.. W's., experience 
would, we believe, accord with our own. 

225. " The length of the feetus, at full time, varies much less than 

* From these remarks it would seem that it is very rare in Europe, at least in 
British Europe, to meet with children, weighing more than twelve pounds. In this 
country, as far as our experience goes, it is not very unfrequentry met with, if com- 
parisons by the eye do not greatly deceive us. I delivered one woman of three chil- 
dren, (at three different births,and all males,) which appeared of the same size at birth : 
and from the very large size of the one I first delivered her of, I prevailed upon the 
parents to permit me to weigh it — it weighed, without clothing, fifteen pounds arid a 
half— the two others were not weighed-, but appeared to be of equal bulk. I have met 
with two ascertained cases of fifteen pounds, and several I believed to be of equal 
weight. I will give the measurements of a child at birth, the weight of which was 
Bot ascertained, from prejudices being entertained against the experiment. This child, 
(a male,) was delivered alive by the forceps ;. as was its brother,.eighteen months before ; 
and which,. I believe, was of equal size, 

Round the forehead and vertex, 1 6 inches 4-8ths. 
Round the shoulders, 19 inches 5-8ths. 

Round the arm below the elbow, 5 inches 6-8ths. 

Velpeau says, that a new-born child of eight or nine pounds, is enormous; and in- 
directly calls in question the veracity of those who affirmed they have witnessed much 
greater weights — did M. V. live in this country, he might often be convinced that 
such things do occur, and that not so. un frequently, as to make them extremely 
rare. 

t Professor of Midwifery at the College of Physicians and Surgeons of the Western 
District of New York. 



OF THE DEVELOPMENT OF THE FCETUS. 83 

its weight. Roederer concludes, from his examinations, that the ave- 
rage length of a male child, is twenty inches and a third, while that 
of a female is nineteen inches and seventeen-eighteenths. Petit as- 
signs twenty-one inches as the usual length. Hutchinson says, it is 
ordinary from nineteen to twenty-two inches, and seventeen and twenty- 
six inches will include the two extremes,* excepting some very rare 
cases, while Fodere and Capuron place the extremes from sixteen to 
twenty-three inches. This last author attaches great importance to 
the difference in the proportion between the length of the superior and 
inferior parts of the body, and he conceives that attention to this, is 
one of the best modes of verifying the age of the foetus. As a gene- 
ral rule, there will be an equilibrium between the upper and lower 
parts of the body at the ordinary term of gestation, and the navel will 
be at the middle of the body, or nearly so. Before that time, the 
middle will approach nearer the head. 

226. " It is evident, that the signs drawn from the structure, weight 
and dimensions of the child, are liable to some variety, and this de- 
pends on various circumstances, such as the age and vigour of the 
mother, her mode of life, the diseases to which she may have been 
subject, and probably the climate in which she lives." P. 170. 

227. From what has been said, it must be certain, that the foetus, 
like every other product, will be liable to a variety of contingencies 
in its progress from the germinal, to the fully expanded state ; and, 
consequently, that the laws of development may be imperfectly, or 
irregularly, too slowly, or too rapidly performed, which will, as one 
or the other of these conditions prevail, give rise to a considerable 
difference in the appearance of the newly born child. 

228. If the laws of development be imperfectly or irregularly per- 
formed, the fcetus may be defective in some of its parts ; or it maybe 
natural, or excessive in other portions of its body. If too slowly de- 
veloped, it will exhibit the marks of immaturity, but not (perhaps 
necessarily,) of imperfection. If this be too rapidly performed, there 
will be evidences of it, in the excessive though perfect size of all its 
members. In a medicolegal point of view it is sometimes of great 
consequence to decide between immaturity of development, and the 
imperfection of development of the foetus ; the first has relation to the 
time it may have tarried in the uterus ; while the second depends 
upon the manner in which development has proceeded, or has been 
performed in utero. These two conditions of the fcetus, it will easily 
be perceived, may have a very important influence in certain cases, 
as one or other may exist. On the one hand when development is 
performed too rapidly, or excessively, it may give rise to very impor- 
tant consequences, as we shall attempt to show presently. 

229. While, on the other, the instances of retarded development 
are by no means uncommon ; and when this occurs, it may occasion 
much error of deduction ; especially, when this is based upon the 

* I once delivered a child, that measured twenty. seven inches in length. 



84 OF THE DEVELOPMENT OF THE FCETUS. 

mere appearance of the child. In some instances it may involve the 
happiness and character of the individuals with whom this deficiency 
of organic power may prevail ; it, therefore, merits serious attention. 
And again, causes may operate to hasten, or rather to augment deve- 
lopment. So much so is this the case, sometimes,, as to lead to con- 
clusions equally disastrous to the reputation and happiness of the 
individuals concerned, in the event of its becoming a medico-legal 
question. We shall cite an example of each kind. 

230. One of the most remarkable of the first kind, - is that related 
in the " Clinique d'Aecouchemens de Pavie," reported by Dr. Lc~ 
vate.* This case is recorded as an instance of premature delivery at 
the fifth month, though the woman believed herself to have arrived at 
full term. The reporter declares, that " every appearance announced 
the opinion of the woman to be correct ; this was her sixth pregnancy; 
and she had been, previously to impregnation, perfectly regular in her 
catamenial discharges. Eight menstrual periods had passed without 
any discharge ; the abdomen swelled progressively and regularly ; 
the child was felt for several months ; the neck of the uterus was 
very short, and the lower segment of the uterine cavity was much 
developed; the head of the foetus was easily felt, but w T as very mo- 
veable. The uterus reached to the epigastric region ; and the abdo- 
men was very voluminous. On the 28th November, 1824, this woman 
was delivered naturally of a living, but a feeble child, and appeared 
not to be more than five months ; it lived some hours. It weighed 
two pounds ten ounces, measured thirteen inches and nine lines, and 
there was a great disproportion in length between the inferior and 
superior parts, from about the umbilicus. The waters weighed more 
than ten pounds, escaped with the dependencies of the foetus." This 
extraordinary accumulation of the liquor amnii, is considered as the 
cause of the error of the period of gestation^ and of the premature 
birth of the child. 

231. Though the reporter of this case looks upon the great quan- 
tity of water as the cause of error in the woman's calculation of her 
advancement in pregnancy, as well as the cause of the premature de- 
livery, (as he thinks it ;) yet the history of the ease appears to afford 
the strongest ground for the belief that the woman went her full time ; 
and that the under size and weight of the child were owing to its in- 
complete development. In the first place, eight menstrual periods 
had elapsed without discharges, before the birth of the foetus ; and 
this took place with a woman, who had been perfectly regular before. 

Now T , though we do not hold this circumstance in itself to be con- 
clusive, yet it must be looked upon as strongly presumptive, that the 
arrest of the catamenia was owing to impregnation ; as the abdomen 
began to enlarge regularly from this time ; and the stirrings of the 
child were perceived several months. If we add to these facts, the 
condition of the neck of the uterus, the ascent of its fundus to the 

* Revue Medieale r Vol. III. 



OF THE DEVELOPMENT OF THE FCETUS. 85 

epigastrium, and the facility with which the head of the child was felt, 
they would seem to be conclusive, that the woman had gone to the 
full period of utero-gestation. Besides, the weight and measurement 
of the child vastly exceed those of a fcetus of but five months. 

232. In general, a fcetus at five months measures, agreeably to 
Hamilton, and our own frequent observation, not more than from six 
to seven inches,* and weighs but a few ounces ; whereas, in the case 
in question the fcetus measured double this number of inches, and 
weighed more than six times the ordinary weight of one at five months. 
Besides, it is expressly stated that the mother felt the stirrings of the 
child during several months previously to its birth. Now, the common 
period of quickening is about the fourth month. It is true, that this 
circumstance, if taken alone, might be liable to some objection ; as 
women have declared they have perceived this sensation as early as 
the twelfth week ; but if the regular development of the uterus be 
taken into consideration (and it is declared, that at the time of deli- 
very, its fundus had reached the epigastrium,) it justly acquires much, 
and deserved weight. 

233. The author of the observation is of opinion, as we have stated, 
that the extraordinary accumulation of waters, was the cause of the 
error in the calculation of the period of gestation, as well as what he 
supposes the premature expulsion of the fcetus ; but we cannot agree 
with him in his conclusions for the following reasons : 1st, because it 
is stated that after the cessation of the menstrual discharge, the belly 
increased " progressively and regularly ;" and consequently, if thisi 
enlargement depended, as is supposed, upon liquor amnii being en- 
closed within the uterus, the liquor amnii must have existed before 
conception had taken place ; a circumstance, hitherto, we are dis- 
posed to believe, which has never been insisted on. 2d. Because 
this explanation supposes that the liquor amnii can be furnished inde- 
pendently of the amnios ; for if the uterus was regularly developed, as 
it is declared to have been from the first stoppage of die catamenia ; 
and if this development was occasioned by the liquor amnii that 
fluid must have been produced by the covering of the fcetus ; and if 
this be admitted, the fcetus must have existed as early as the liquor 
amnii; and if this be granted, it must date its age from the time the 
menses were interrupted, which will make it a child at full period ; 
but one which had been imperfectly developed. 3d. Because it is a 
very common occurrence, to have a large collection of the liquor 
amnii, when the fcetus is but ill-developed, where there is no suspi- 
cion that the woman has not arrived at full time. 4th. Because, in 
the case in question, there was no preternatural distention of the uterus, 
to render it probable that it was developed in so short a period as five 
months, to a size equal to that at the last period of gestation, from 
the mere excess of the liquor amnii, as the united weights of the fcetus, 

* Dr. Beck says, (211,) the length is from seven to nine, and weight nine or ten 
ounces : we are certain that boih the measurement and weight arc excee.-ive .is a gene- 
ral rule. 



86 OF THE DEVELOPMENT OF THE FCETUS. 

(2 lbs. 10 oz.) and of the waters, (10 lbs.) will not exceed the average 
weights of these two substances at the ordinary full period of gesta- 
tion. 

234. It may be said that the liquor amnii was so largely and sud- 
denly furnished as to give the uterine development the appearance of 
maturity ; though the woman may have been but five months impreg- 
nated : but this supposition is entirely destroyed by the facts connect- 
ed with the first interruption of the menses ; for it is expressly stated, 
that the belly began to swell "regularly and progressively," and that 
"the neck of the uterus was very short," and ''that the lower seg- 
ment of its cavity was much developed." Besides, we must insist, 
that there is no example, in our opinion, extant, of a foetus of five 
months weighing two pounds ten ounces. Again ; the woman herself 
was of opinion, that she had arrived at her full time ; and her impres- 
sion on this subject is certainly entitled to some consideration, as she 
had had five children before, and could not very well be mistaken 
when she said she had felt her child several months before the period 
of labour. 

235. I would inquire, moreover, whether any accoucheur could 
easily feel the head of a foetus by an examination per vaginam, at the 
fifth month of pregnancy. Indeed, at this period it is not always safe 
to declare the woman to be pregnant, much less to determine, that 
the head is the presenting part, and that it is very moveable ; for as 
the neck of the uterus has lost nothing of its length, at this time, and 
as the uterine parietes are very rigid and pretty thick about this period, 
we are of opinion that much difficulty would attend forming a deci- 
sion that would be free from all error. As regards ourselves, we have 
no hesitation to believe this case to be one of retarded or imperfect 
development of the foetus : and that its application to medico-legal in- 
vestigations may be highly important. 

236. We have stated above, that the development of the foetus 
may be more rapid and perfect than ordinary, as well as unusually de- 
fective ; and when this takes place, it may also give rise to very serious 
consequences, if the possibility of such an occurrence become a ques- 
tion, before a legal tribunal. As we are of opinion that this pretty 
frequently happens, we will relate a case, which had nearly become a 
subject of inquiry, before one of our courts, by a suit for a divorce. 

237. In November, 1810, 1 was called to attend a female in labour 
with her first child. The woman had been very suddenly attacked 
with severe pains, in consequence, as was supposed, of great agitation 
of mind. On examination, I found the uterus was not completely de- 
veloped ; as a portion of the neck was still to be felt. I inquired of 
the patient, whether she thought herself at her full period ; she an- 
swered, no ; she was but seven months gone. — After several hours of 
very severe suffering, she was delivered of a large boy ; at least, large 
for seven months. I, however, made no observations upon the case 
at the moment, as I was an entire stranger to the circumstances of my 
patient; though the size of the child was remarked by an old woman, 



OF THE DEVELOPEMEJST OF THE F02TTJS. 87 

mother of the husband, who said, it was " the finest seven month's 
child she had ever seen." It is certain, the child bore every mark of 
greater maturity than is usual with children born at the seventh month 
of utero-gestation. 

238. Some months after this period, I was called upon and examined 
before a magistrate and two lawyers ; this was a preliminary step to a 
suit for divorce, which was intended should be sued for by the hus- 
band of my patient, if certain opinions derived from me, were favour- 
able to such an undertaking. 

239. The following circumstances were alleged on the part of the 
intended prosecution, before the magistrate and the two lawyers : 1st. 
That at the period of the birth of the child, but seven months had 
elapsed, since the marriage of the parties. 2d. That at the time of 
the marriage, the husband had been from sea but two days, and this 
after an absence of some months. 3d. That at the end of seven 
months the wife w r as delivered of a full-grown child.* It was there- 
fore declared, that the woman was pregnant before marriage, and that, 
not by her husband ; a bill of divorce w 7 as therefore intended to be 
prayed for. 

240. On the part of the wife it was proved, she had sustained an 
irreproachable character ; that she was an industrious, domestic woman ; 
not visited by, or known to associate with any man in particular ; that 
she had during the whole time lived with the mother of her husband, 
and that she had had her menstrual period but a few days before her mar- 
riage, and that she had not had them since her marriage. 

241. My evidence went to say, that at the period of labour, the 
neck of the uterus was developed rather more than was usual at the 
seventh month, but was not effaced ; which gave rise, on my part, to 
the question, as above stated, whether the patient thought herself at 
her full term, and which drew from her the answer, that she was " but 
seven months advanced in her pregnancy ;" and that my opinion and 
belief were, that she was not in error as regarded her calculation ; 
though the child was very considerably larger than is usual at the 
seventh month. That violent mental excitement was a frequent cause 
of abortion, and of premature delivery ; and it had been proved, that 
this woman had experienced great mental anxiety, as well as felt great 
anger, the day previous to her experiencing any thing like the pains 
of labour ; and that this mental agitation might have occasioned the 
premature delivery. 

242. That the development of the foetus is by no means regular ; 
that it is notorious, that some women bear much larger children than 
others ; that the average weight of a newly born child is fixed in this 
country, at between seven and eight pounds. Now, it must be evi- 
dent, from an average being fixed upon, that there must necessarily 
be many children whose weights must exceed the stipulated weight 

* It was stated, that after 1 had left the house, it was suggested by some one present, 
that it might be well to weigh the child : this was done ; and it was ascertained to weigh 
between six and seven pounds. 



88 OF THE DEVELOPMENT OF THE FOETUS. 

or average ; and many others fall below it. And though it was my 
belief, that the weight of the child in question, was nearly equal to the 
average proportion ; yet that this, in itself, did not by any means prove 
it had arrived at full time ; as all such children whose respective 
weights may exceed the average, and particularly those which may 
weigh from twelve to fifteen pounds at birth, (a thing not very unusual,) 
must necessarily have weighed more than the average at seven months ; 
and, consequently, the weight of the child cannot mark the period 
of gestation with so much precision, as to render it free from all 
error. 

243. That the fact just stated, must strike every body as an irre- 
sistible truth ; and, consequently, that this might have happened in 
the case in question ; or, in other words, as it is indisputable, that 
many children at birth exceed the average weight, it must follow, 
that the less weight must be attained before the greater ; and that in 
cases of excessively heavy children, six or seven pounds would not 
be an extravagant weight for a child at seven months, that might 
weigh nearly double, if carried to the full period of utero-gestation ; 
and, that there could be no possible reason assigned, why this 
might not have happened, in the case in question. 

244. The husband was so entirely satisfied of this possibility, that 
he abandoned all farther intention of a prosecution. 

245. A diseased condition of the mother may sometimes interrupt 
the regular development of the foetus ; but this is by no means so fre- 
quent as might at first sight be imagined, even where this might 
reasonably be expected. For in cases of long-protracted illness, 
where the mother has suffered great emaciation, the child has often 
been found, contrary to all expectation, well developed, and ap- 
parently healthy. Yet it now and then occurs that the increase of 
the foetus has not kept pace with the period of utero-gestation. An 
instance of this kind fell under my own observation ; and in which 
there could be no possible error in the calculation, if any reliance 

• can be put upon human asseveration. Mrs. was taken in 

labour at the end of the seventh month of gestation, and was speedily 
delivered of a foetus of about five inches in length, and might proba- 
bly have weighed three ounces ; it breathed very imperfectly a few 
minutes, and then died. 

246. Upon my declaring to my patient, that she had made a great 
mistake in her calculation, as the child, could not at farthest be more 
than five months, she said it was impossible, from circumstances, 
that any error could exist ; and, that she was every way certain it 
must be full seven months. Presuming what might be the "circum- 
stances" alluded to, I inquired of the husband, whether my conjec- 
ture relative to them, (namely, that no intercourse had taken place 
for that length of time,) were correct: he assured me they were ; as 
the health of his wife had so rapidly declined at about that time, as 
to prevent any union from taking place. 

247. Again, we are intimately acquainted with a lady, (whom we 



OF THE ACTION OF THE UTERUS. 89 

have delivered of nine children at full term,) who never has pro* 
duced a child that would have weighed, at birth, five pounds. 
Yet this lady enjoyed an uninterrupted state of health ; made an 
excellent nurse ; and at the end of a year her children were as large 
and as healthy as children usually are at this period. This lady was 
subject to no disease during gestation ; she did not even suffer the 
usual penalties of pregnancy ; for she was exempt from both nausea 
and vomiting. 

24S. In treating of subjects, which have a relation to medical 
jurisprudence, it may be thought, by some, I have rather wandered 
from the strict path which my professed object points out. But in 
this I do not agree. First. Because I do not meddle with any sub- 
ject of a medico-legal kind, that has not an intimate, and perhaps 
entire connection with midwifery. Second. Because on the intimate 
knowledge of this branch, some of the most important testimony 
almost exclusively depends. Third. Because some of the most fre- 
quent, as well as interesting objects of medical jurisprudence, as 
infanticide, supposed pregnancy, supposed delivery, rape, &c. are 
dependent, almost altogether, upon the evidence of the accoucheur. 
Fourth. Because there are points in each of the cases just named, 
which can only be elucidated by the experienced practitioner of mid- 
wifery. Fifth. Because there is much ignorance as well as discre- 
pancy betrayed in the testimony of physicians, who may practise, 
(and even extensively,) this branch, when called into a court of 
justice, from the want of the knowledge of the subjects, at which we 
have rather glanced, than professedly treated. 

249. Besides, in doing this, I hoped to awaken an interest to the 
subject of medical jurisprudence in those (and they are by very far 
the greater number,) who have hitherto paid no attention to the 
subject, by bringing before them quotations from Dr. Beck's admira- 
ble work on this subject, and thus induce them to possess themselves 
of it. 



• CHAPTER VIII. 

OF THE ACTION OF THE UTERUS. 

250. The uterus exerts two kinds of action : first, that action 
which tends to reduce itself to its original size after having been 
distended, and the distending Cause has been removed ; this is called 
by Baudelocque and others, the tonic action of the uterus. This 
action is performed by all the fibres of this organ gathering them- 
selves up towards a Common centre; but more especially, by that 
class of fibres we shall denominate the "circular fibres;" the other 
9 



90 OF THE ACTION OF THE UTERUS. 

fibres are those we shall call the longitudinal, not acting with a force 
equal to the other; hence the lengthened form of the uterus. 

251. The tonic action of the uterus can be exerted in various de- 
grees, as it may possess its inherent powers in a greater or less state 
of perfection; it may exist under the following conditions, and va- 
rieties : 1st. It may act with the most perfect uniformity and suc- 
cess for the purposes for which it is intended. 2d. It may be 
impaired so as to act transitorily and feebly. 3d. It may act with 
force at one moment, and cease the next. 4th. It may act par- 
tially ; that is, the fundus may contract, and the body and neck be 
flaccid ; the body may contract, and the fundus and neck be re- 
laxed ; the neck may contract, and the body and fundus be in a 
state of atony ; the body and fundus may contract, and the mouth 
be relaxed : when these occur, different phenomena present them- 
selves. Leveret and others have admitted the tonic power of the 
uterus to continue even after visible life had ceased ; and, however 
much this circumstance may excite our surprise, or challenge our 
belief, it is, nevertheless, authenticated by various testimony. The 
latest instance of this kind I have met with, is recorded in the 
Edin. Med. and Surgical Journal, No. VI. of new series, p. 431, and 
related as follows, by Professor Herrmann, of Bern. 

252. " On the ihird day after the death of a young woman who 
was in her sixth month of pregnancy, the nurse heard a loud noise 
proceed from the corpse. A physician was immediately sent for, 
who, on his arrival, found that the deceased had brought forth twins, 
which were enclosed in a membrane, quite entire, and not in the 
least putrid. The placenta only appeared to have suffered from the 
effects of putrefaction." 

253. Leroux also mentions a case of the contractile force continu- 
ing after death, from his observation.* He says he was called to a 
woman in labour, ( who died about a quarter of an hour before his 
arrival. He was about to perform the Cassarian section, when he 
saw an arm of the child without the vulva, and to which was 
attached a string. This had been applied by the women who were 
present, who had drawn by it so severely as to fracture the child's 
arm. He reprimanded them severely for their cruelty and ignorance ; 
and, with a view to demonstrate to them how easily the lives of 
mother and child might have been saved, he turned and delivered 
the child without the least difficulty. In doing this, however, he 
perceived the uterus to contract in proportion as the child was with- 
drawing, as if the woman were living. He was surprised at this, 
and introduced his hand into the uterus to convince himself of the 
fact; he found it contracted evenly, and the mouth of the uterus 
opposed the introduction of his hand. Doubting the woman to be 
dead, he employed the most active means for her recovery, but 
without success. 

254* Secondly, the uterus possesses the power of alternate action : 

* Obser. sur les pertes de Sang, &c. p. 29. ob. xiii. 



OF THE ACTION OF THE UTERUS. 91 

this action manifests itself only when attempting to expel something 
from its cavity ; but can never do so, unless the tonic contraction 
is in a state of greater or less perfection. It never does take place, 
therefore, so long as the uterus is in a state of atony. This contrac- 
tion has also been termed the spasmodic, or painful contraction of 
the uterus ; as, for the most part, it is accompanied by pain. It is 
always the effect of stimuli, or mechanical irritation ; hence it ap- 
pears during labour ; daring abortion ; or in the form of after-pains, 
to expel coagula or any other foreign substances, as in dysmenor- 
rhea.* It is almost always attended by pain, but not necessarily : 
when pain attends, it is not because it is an inevitable consequence 
of contraction, but by reason of some change which the muscular 
fibre has undergone from civilization, refinement, or disease. f We 
see it sometimes most efficiently excited without pain, as in the la- 
bours of the aboriginal women of this country : in the women of 
Calabria, and, among some, even in this our artificial state of society. 
It tends, during its best action, to diminish the cavity of the uterus, 
and, consequently, to expel its contents ; but its effects are but 
transitory ; the uterus returns to the condition it was in before this 
contraction took place, and remains quiescent, until it is, by its 
proper stimulus, again called into action — thus alternating for a 
longer or shorter period ; and now constitutes what is usually called 
u labour pains." This contraction is most successfully exerted when 
all the fibres composing the body and fundus of the uterus act simul- 
taneously — for when it acts partially, it is more painful than when 
the action is general, and never achieves the object it is intended to 
effect. 

255. In the brute, this contraction is successively exerted without 
the intervention of pain ; unless the labour be complicated with dis- 

* It must not be supposed that the " labour pains" which declare themselves at the 
end of nine months in cases of extra-uterine conception, form an exception to this 
rule; for in these cases, the decidua is always produced; but at this period it 
becomes an extraneous substance, and uterine contractions are established, to ex- 
pel it. 

t Several cases of such rapidity of labour have occurred lately, as to attract the at- 
tention of the medico-legal writers to the subject. A remarkable instance of this 
kind has recently happened at Arras, in France. A woman, aired twenty-two years, 
in the last month of pregnancy, was taken with some pain in tlic bowels, and think- 
ing that she was going to have a stool, repaired to the "Carderobc." It was in the 
night. She had scarcely sat down, when her infant was born without any pain, or the 
least notice, and it fell into the privy below ! She knew nothing of what had happened, 
till she heard the cries of the child. It was three hours before it cou'd be liberated. 
It could not be resuscitated. — Non. Medko-Chirurg: Review, Sept. 1824. 

As the absence of pain, during the efficient alternate contractions of the uterus, is 
disbelieved by some practitioners of midwifery, who have seen considerable shares of 
business, I avail myself of the testimony of Dr. Campbell to this point. Although far 
the greater part of the sex bring forth with pain, yet some few arc met with, who have 
very little, or none at all. I knew a lady who in three successive confinements was 
not aware she was in labour, until rising Trom an arm-chair on which she had been 
sittfag, a sensation was communicated to her, which compelled her to call for assist- 
ance ; and ?he could scarcely be got to bed in the same room when the child was 
born. — Infr. to the Study and Practice of Med. p. 170. 



92 OF THE ACTION OF THE UTERUS. 

ease, or accident. When either of these occur, the same consequences 
follow — .namely, pain. It would be wrong, therefore, to suppose, 
that the labour of the female brute is performed upon a different prin- 
ciple from the human female, because she is, for the most part, exempt 
from pain — for truly, the same general process occurs in both ; and in 
each, the uterus exerts the same kind of action : the only difference is, 
the one is performed with pain, and the other without. It has been 
supposed by some, from the mere absence of pain in the brute, that 
the foetus is expelled by one uniform, but sufficiently long-continued 
effort, without the intervention of the alternate contraction ; but this 
is not so — as any one may at once convince himself, by observing 
the progress of labour in almost any of our domestic animals. It will 
be distinctly, and easily perceived, that there is from time to time, a 
suspension of uterine effort, and a repetition of it : marking, most 
conspicuously, the intervention of the alternate contraction. 

256. In the brute the alternate contraction is attended with pain, 
when the uterus is provoked by accident or disease, to severer exer- 
tion than ordinary— and when this happens, their sufferings are as great, 
cseteris paribus, as those of the human female. From this it would ap- 
pear, that such a condition of fibre may be accidentally induced in them, 
as is pretty permanently fixed in the other. The alternate contraction 
would appear to be nothing more than a sudden and an exalted degree of 
the tonic ; and the pain which so usually attends this action, arises from 
some morbid or altered condition of nervous energy in the muscular 
fibres composing the uterus. This would seem to be proved by the 
effects which have followed civilization and refinement — and the 
consequences of domestication may be traced in those animals which 
participate with man in his departure from his original simplicity ; for 
we are informed, that the artificial condition to which the cow, es- 
pecially, is reduced by domestication, in and near great cities, sub- 
jects her to more difficult and dangerous labours, than those in the 
natural, or less artificial state. 

257. So far as we can determine the point, it seems, that the lon- 
gitudinal fibres of the body in general, and those of the uterus in par- 
ticular, have more especially felt the influence of the causes just men- 
tioned : for man is said to have lost much of his original vigour and 
Strength; and women suffer from child-bearing; while the circular 
muscles and sphincters appear to have lost nothing of their primitive 
power: thus, the heart and intestines have parted, perhaps with none 
of the original vigour with which from the beginning of the world 
they were endowed ; nor have the several sphincters, among which 
the orifice of the uterus may be justly reckoned, suffered from con- 
stitutional abuses. 

258. In the uterus in particular, we may observe pretty nearly the 
same thing — for I hold it more than probable, that the circular fibres 
of this organ have not deteriorated in the same degree as the longitu- 
dinal, nor are they subject precisely to the same penalty, since they 



OF DISPLACEMENTS OF THE UTERUS. 93 

ma)" contract with great force, without the production of pain. We 
see this well and satisfactorily illustrated in that condition of the body 
of the uterus, called the hour-glass contraction. This state may con- 
tinue for hours, without being attended by pain. 

259. The contractions of the uterus are entirely independent of the 
will ; their intervals can neither be accelerated nor retarded by any 
exertion of it ; nor can their force be either augmented or diminished, 
by its influence ; but passions and emotions of the mind, when strong, 
oftentimes exert a powerful influence over uterine action — they may 
call it into play, at a time the least expected ; or may suspend it, after 
it has been strongly excited. The first is proved by passions and 
emotions being often followed by abortion : and the latter by the fol- 
lowing fact, which fell under my own notice : — In 1792, I was called 

to attend a Mrs. C , in consequence of her midwife being engaged. 

As I approached the house, I was most earnestly solicited to hasten 
in, as not a moment was to be lost. I was suddenly shown into Mrs. 
C's. chamber, and my appearance there was explained, by stating 
that her midwife was engaged. As I entered the room, Mrs. C. was 
just recovering from a pain — and it was the last she had at that time. 
After waiting an hour in the expectation of a return of labour, I took 
my leave, and was not again summoned to her for precisely two weeks. 
And Dr. Lyall says, "We have been informed by a respectable prac- 
titioner, of a labour that had nearly arrived at its apparent termination, 
suspended for more than two days, in consequence of a gentleman 
having been sent to the patient, against whom she had taken a pre- 
judice."* Every accoucheur has experienced a temporary suspension 
of pain upon his first appearance in the sick chamber ; but so long a, 
period as two weeks is very rare. 



CHAPTER IX. 



OF DISPLACEMENTS OF THE UTERUS. 



260. Notwithstanding the uterus has four ligaments, purporting to 
support and sustain it in situ ; yet this is so ill-performed, as to ren- 
der it very doubtful whether such was the express intention of nature 
in their formation. Certain, it is, the uterus is subject to the impulses 
of the abdominal viscera; to the pressure of the distended bladder; 
and to the influence of the loaded rectum and sigmoid flexion of the 
colon : and we may add, to the consequences of its own internal 
weight after conception. 

* Sec Minutes of the medical' evidence given in the Gardner Peerage cause. 

9* 



94 RETROVERSION OF THE UTERUS. 

Sect. I. — Of Prolapsus from Pregnancy. 

261. The latter of the causes just enumerated, (260) very often sink 
the uterus so low in the pelvis, as to make it completely occupy the 
vagina ; and it sometimes even discovers a disposition to escape from 
the os externum— this subjects the woman, when excessive, to cer- 
tain inconveniences; but to none, when moderate; except, perhaps, 
a sensation, as if something w T ere escaping from the vagina, when she 
is in an erect posture ; but this is almost instantly relieved, when she 
disposes herself in a horizontal position. When more excessive, it 
creates embarrassments to the flow of urine, and the discharge of feces. 
These inconveniences rarely require medical interference ; as they are 
relieved after a short time, when the uterus acquires a sufficient bulk 
to rise out of the brim of the pelvis. When interference is required, 
the application of a proper pessary is all that is necessary. 

262. I recollect distinctly but two instances, in which it was ne- 
cessary to introduce the catheter — for the woman is easily instructed 
to lie upon her back with her hips a little elevated when she is im- 
portuned to pass her urine ; or readily taught to press back the uterus 
with her finger, should not this succeed : or to go upon her knees, 
which has, in several instances been all that was necessary. 

263. It is, however, liable to some other derangements, which are 
much more difficult to remove, and much more serious in their con- 
sequences : these are the retroversion and anteversion, as well as the 
prolapsus, when pregnancy has no agency in it„ 

Sect. Il.-^-Retroversion of the Uterus* 

264. The retroversion, is that displacement of the uterus, in which 
the fundus is precipitated backwards, and places itself between the 
rectum and bladder in such a manner as to be readily felt, behind the 
vagina, upon the introduction of the finger into it, while the neck is 
mounted up, behind the symphysis pubis. 

265. This situation of the uterus, was: not distinctly known, until 
Dr. W. Hunter, (Med. Obs. Vols. IV. and V.) in 1754, favoured the 
world with an account of it,, accompanied by accurate drawings of the 
|>arts. Since that period, this disease has claimed much attention, and 
is now perfectly well understood by all well-instructed accoucheurs. 
It is not, however, regarded of equal consequence by all : while 
Hunter, Baudeloeque, Meygrier, Burns, &c > look upon it as an acci- 
dent of serious moment ; others, as Denman and Merriman, view it 
almost with careless, indifference. As both cannot be right, we shall, 
in the prosecution of this subject, attempt to show which of the opi- 
nions has,, in our estimation, the strongest claims to confidence. 

266. This deranged situation of the uterus may take place in its 
unimpregnated, as well as in its impregnated state — the latter is, how- 
ever, by far the more common. It usually takes place between the 
second, and the fourth months of pregnancy, as after the latter period, 



RETROVERSION OF THE UTERUS. 



95 



the length and thickness of the uterus will exceed the opening of the 
superior strait, and prevent its folding down upon itself. (See 199.) 

267. The remote cause of this complaint is, whatever tends to de- 
press the fundus; and may be external violence, such as blows, pres- 
sure, sudden exertion, &c, or violent efforts to vomit, violent cough- 
ing, an over distended bladder ; or, perhaps, an unusual accumulation 
of feces in the rectum, or sigmoid flexion of the colon. These causes 
may operate suddenly, so as instantly to produce the disease ; or 
slowly, requiring a long time for its completion. 

26S. The symptoms produced by this unnatural situation of the 
uterus, be may more or less violent, according to the size it may have 
acquired ; or as the displacement may have been suddenly or slowly 
produced. When suddenly induced, the symptoms are usually vio- 
lent and alarming — such as an immediate interruption to the flow of 
urine, or permitting it to pass with great difficulty ; or a stoppage of 
the feces ; alternate pains, accompanied by great forcing or bearing 
down ; a disposition to faint, &c. When considerable time is spent 
in completing this displacement, the evils arising from it are less 
urgent and severe, because the parts gradually become accustomed to 
their new situation. But in either case, if the uterus be not restored, 
the symptoms increase in intensity ; and instead of a difficulty, and 
frequent inclination to make water, there will be a total suppression 
of it, accompanied by a painfully intense desire to pass it — for the 
foetus goes on to increase in size, and the uterus to develope itself; 
thus giving additional pressure to the parts with which it is in con- 
tact. 

269. When this accident happens in the unimpregnated state of 
the uterus, the symptoms, so far as I have observed, are never so dis- 
tressing ; the reason for this will be easily comprehended ; but the 
parts do not become entirely reconciled to their new situation. In 
the impregnated state, however, so much restraint is not imposed 
upon the uterus, as to prevent its farther development, as we have 
already stated ; but the effects of this increase can most readily be 
anticipated. Experience has abundantly shown, that if the fundus 
be not restored, the uterus will go on to augment, so as at last to 
completely occupy the cavity of the pelvis.* This distinctly points 
out the time for the restoration of the fundus uteri. 

270. The symptoms I have enumerated may, however, proceed 
from other causes; it will, therefore, be proper to ascertain by the 
touch the situation of the uterus, so soon as symptoms become urgent. 
If retroversion have taken place, a roundish tumour is felt at the pos- 
terior and inferior part of the lower strait occupying more or less 
room, as the uterus may be a longer or shorter time impregnated, or 
as it may have been a longer or snorter time displaced. The finger 
cannot touch the projection of the sacrum ; but may gain a passage 

* See Dr. lluntcr'd Case. Med. Obs. and Inq. ; also„Wilmer's Cases, p. 144. 



96 RETROVERSION OF THE UTERUS. 

to the upper strait, immediately behind the symphysis pubis, where 
if the neck has not mounted too high, the os tinea? may be felt. 

271. This disease may be mistaken for a prolapsus uteri ; but can 
most easily be distinguished from it : 1st, In the retroversion-, the 
vagina interposes between the finger and the tumour ; and the neck 
of the uterus is mounted up behind the symphysis pubis. 2d. By 
the absence of the neck of the uterus, which is always found in ad- 
vance of the body and fundus, in a prolapsus. 3d. By the symptoms 
never being so extreme, in the latter. 4th. By the prolapsed uterus 
almost always being moveable ; whereas, in the retroversion, it is ob- 
stinately fixed. It may also, according to Mr. Burns, be confounded 
with a diseased ovarium, when it may chance to occupy this place ; 
or with an extra-uterine conception, when it may have placed itself 
between the rectum and vagina ; these two complaints may be dis- 
tinguished by noticing, that in both the diseased ovarium, and the 
extra-uterine conception, the neck of the uterus is always within reach 
of the finger ; and also that a long catheter may be readily passed 
in the natural axis of the uterus; for I believe the fundus would not 
be carried down by either of these bodies. 

272. I may, moreover, observe, that both ovarial tumours and ex- 
tra-uterine conceptions are of slow and regular progress; especially, 
perhaps, the latter ; therefore, should it produce symptoms analogous 
to retroversion,, they would be of very gradual increase ; and would 
require a long time for the symptoms to become imperative. 

27£. Dr. Denman has well described the mechanism of this ac- 
cident ; but we cannot agree with him entirely as to its cause" ; he 
considers that a distended bladder is always the immediate cause of 
retroversion, and that a suppression of urine is absolute only before 
or during the act of retroverting ; therefore, a stoppage of the water 
is the cause, and not the consequence of this complaint, as we have 
declared it to be, (268.) We cannot, however, subscribe to this doc- 
trine ; and for the following reasons: 1st. Because we are certain 
that it has been suddenly produced by violence, and without the in- 
tervention of a suppression of urine. Baudelocque also declares the 
same thing. 2d. Because Baudelocque demonstrated to his class a 
slow retroversion which lasted three or four weeks before it was com- 
plete : in this case, there is no mention of any difficulty in making 
water. 

274. Dr. Denman declares, also, that <c the uterus must be elevated 
before it can be retro verted." To disprove this, it is only necessary 
to recur to those cases which have been suddenly induced, as I my- 
self have witnessed, from external violences ; though I admit that the 
elevation of the uterus would render it more easy of retroversion-, 
were the remote causes acting at the same time. For were the eleva- 
tion of the uterus essential to its becoming retroverted, how should 
it ever take place in the unimpregnated state ? a circumstance I have 
more than once seen. In one instance to which I was called, the pa- 
tient had been delivered but a few weeks. In this case the symptoms 



RETROVERSION OF THE UTERUS. 



97 



were very distressing, as was witnessed by my friend Dr. Parrish ; 
nor were they relieved, until the uterus was restored by manual ex- 
ertion. 

275. The diagnosis of this complaint, as given by Dr. Denman, 
will readily lead to the explanation of his considering this a trifling 
disease: he says, "If a woman about the third month of pregnancy, 
has a suppression of urine continuing a certain length of time, and 
producing a certain degree of distention of the bladder, we may be 
sure that the uterus is retroverted." Should a mere suppression of 
urine in a pregnant woman really indicate a retroversion, as is de- 
clared by this gentleman, we can readily account for his indifference 
to its consequences, and his trusting its cure to nature, or the 
occasional drawing off the water by the catheter. The young prac- 
titioner is forewarned against this uncertain sign, and plan of treat- 
ment. On the contrary, he is to look upon this complaint as one of 
eventual, if not of immediate danger; especially, when the tem- 
porizing plan we shall now speak of, does not succeed. 

276. As the most pressing symptom in retroversion is the inter- 
ruption of the urine, we must most sedulously endeavour to prevent 
its continuing too long; and the consequences of delay ought to be 
candidly stated to the woman, should she permit her delicacy to 
interrupt an essential point of duty. The catheter should be em- 
ployed pro re nata ; and the bowels emptied daily, either by medicine 
of a milk kind, or by injections; if this plan do not succeed in re- 
storing the fundus, in a short time,* we should then maturely consider 
the propriety of replacing it mechanically. To aid our judgment, 
we should consider, first, the period of gestation ; secondly, the 
degree of development of the uterus ; thirdly, the nature or severity 
of existing symptoms. The period of gestation should almost always 
influence our conduct in this complaint; and may lay it down as a 
general rule, the nearer that period approaches four months, the 
greater will be the necessity for acting promptly to procure the re- 
storation of the fundus ; the reason for this is obvious ; every day 
after this will but increase the difficulty of restoration, as the ovum is 
continually augmenting in size. The degree of development should 
also be taken into consideration ; for one uterus may be as much 
expanded at three months, as another is at four ; consequently, if this 
obtain, there is a decided reason for acting earlier, than may at other 
times be necessary; so also at the fourth month, if the development 
be less than is usual for that period, we may, every thing being equal, 
delay the attempt at replacement, if any reason present itself to make 
this eligible. The extent or severity of symptons must ever be kept 
in view ; for instance, we must not temporize too long where the 

* It would be difficult to point out any precise time for temporizing-, as every thing 
must depend upon the emergency of existing symptoms, and these will necessarily be 
influenced by the period of gestation. The interval of time employed by a pro re nata 
plan, should be always shorter, as the period of pregnancy may approach the fourth 
month. 



98 



RETRO VERSION OF THE UTERUS. 



suppression of urine is complete, and cannot be relieved by the 
catheter; lest the bladder become inflamed,* or gangrenous,! or 
burst.J For the bladder, from its very organization, cannot bear dis- 
tention beyond a certain degree, or beyond a certain time, without 
suffering serious mischief. 

277. From this I conclude, that the uterus should in every instance 
be restored, when practicable, at, or very little after, the fourth 
month ; for, if left longer than this, the chance of succeeding is every 
day diminished; and I am firmly of opinion that nothing can justify 
longer delay at this time ; more especially, if it proceed from the vain 
hope, that nature will relieve herself at the full period of gestation. § 

278. The symptoms I have noticed above, should teach us the 
propriety and necessity, of ascertaining the true situation of the 
uterus, by an examination per vaginam ; and until this be done, 
though we may be disposed to hint our suspicions, we should never 
positively affirm, that the patient is labouring under retroversion. For 
I have frequently prescribed a little sweet nitre and laudanum for a 
difficulty of passing water in pregnant women, with the most decided 
success ; and when these symptoms were more severe or obstinate 
than common, I have examined per vaginam, and sometimes without 
finding the uterus in a state of retroversion. 

279. My experience has furnished me with few facts of which I am 
more certain, than that " a certain degree of distention of the bladder" 
may exist, and for a considerable time, without producing retrover- 
sion ; even where I have been under the necessity of using the cathe- 

* Dr. Bell, Med. Facts, Vol. III. p. 32. f Mr. Lynn, Med. Obs. Vol. V. p. 38S. 

X Dr. Squire, Med. Review for 1801. 

§ It is with both surprise and regret, that I observe myself charged with a want of 
precision in the treatment of this complaint, No. III. Vol. IV. third series of the New 
England Journal, &c. After having quoted at length the whole of paragraphs 276 
and 277, the writer says, "We have thought much of this matter, and still do not feel 
satisfied with the course prescribed by Dr. D. in this quotation. We may have ex- 
pressed ourselves too strongly, in saying the ' course prescribed' by the author. His 
language is not very precise, and we understand him as saying and teaching, that 
attempts to reduce the displaced organ need not be made before the fourth, or at a very 
little after the fourth month. This, to us, is not sound doctrine." Nor is it to me ; 
nor have I said, or ever taught, such a doctrine. And it is unfeignedly a matter of 
wonder that such a construction could have been given to what I have advanced in the 
two paragraphs just indicated. For, through the whole of my directions, I have aimed 
at precision ; and in par. 277, I expressly deprecate a delay beyond the fourth month ; 
and distinctly recommend the attempt at reduction without regard to the period of 
gestation, wherever symptoms become pressing ; but until then, I am every way 
willing to temporize, as restoration sometimes takes place spontaneously ; but I be. 
lieve we lose nothing by delay up to the period pointed out, where the condition of the 
bladder does not form the principal indication. 

From what I have seen of this complaint, I am disposed to think, that the reviewer 
will alter his opinions, when he has witnessed more cases than he probably has up to 
this time. I view the complaint in as serious a light as he possibly can ; indeed, I am 
charged by some with having unnecessary fears, and of recommending interference, 
when it is not called for ; it will, therefore, be seen that, on the one hand I am accused 
with too much indifference to the treatment of this complaint ; and on the other with 
absolute temerity. I shall not, however, feel myself guilty of either, until future ex- 
perience proves my present views to be wrong. 



RETROVERSION OF THE UTERUS. 99 

ter. And I am also certain, in retroversion, that the mere removal of 
the urine will but rarely, nay, not once perhaps in ten times, be suffi- 
cient to ensure the spontaneous restoration of the fundus, where the 
complaint is of long standing, or the pregnancy advanced beyond the 
third month. But let me be clearly understood to mean, that the 
precaution of drawing off the water when practicable, and that as fre- 
quently as the exigencies of the case demand, is indispensable, either 
to the spontaneous or artificial replacement of the uterus. 

280. I have great reason to believe, that an exclusive reliance upon 
drawing off the water, has been productive of the most serious evils, 
if not of death itself in some cases : it, therefore, should never be ex- 
clusively trusted to, except at the early period of gestation. If the 
woman approach, or if she exceed the fourth month, the attempt at 
restoration should most unquestionably be made ; nor should it be 
abandoned, but for very strong reasons ; nothing, indeed, but the im- 
possibility of succeeding, should induce us to leave the patient to her 
fate — I say, to her fate ; for, what can we promise ourselves in her 
favour?* 

281. The objections usually urged against the attempt to replace 
the fundus, are, 1st. The hazard of provoking abortion : 2d. That it 
does not always succeed, after strong and repeated efforts. 

282. With respect to the first, there is abundant proof in my own 
experience, as well as that of others,! that abortion is not a necessary, 
though it may be a possible consequence of the attempt. I have 
never seen it follow : therefore the fear of an imaginary evil, must not 
induce us to subject our patient to a serious and positive harm. The 
risk of .abortion is but trifling ; but the neglect of restoration at the 
proper time, is a very serious piece of mismanagement. 

283. As regards the second, if it fail, it must generally be attributed 
to our neglecting the proper moment for acting ; or, when it has not 
been properly performed. Having decided upon the propriety and 
necessity of giving aid to the suffering woman, I shall next give di- 
rections for the best mode of performing this operation. I must first 
consider what forces are operating to prevent the restoration of the 
fundus, before I describe how they are to be overcome ; they will be 
found to be, 1st. A distended bladder. 2d. An impacted rectum; 
and most probably a loaded colon at its sigmoid flexure. 3d. The 
counteracting efforts of the woman herself. 4th. The too great bulk 
of the uterus. 

: . Therefore, the first thing to be accomplished is, the evacua- 
tion of the urine by the catheter; in this, it is said, we cannot always 
succeed. I have never met with such a case but once; and Mr. 
Burns declares the same thing; nay, he even goes farther; he says he 
does not believe it can occur: it must therefore, be very rare.} Dr. 

f-rriman. f See Baudclocrjuc, Hunter, Wall, Meygrier, &c. 

X Since the above was written, a case under the care of my friend Dr. Jackson, and 
myself, has occurred — in this case it was impossible for several hours to pass the ca- 
theter. By leeching, and injections, however, this difficulty was eventually overcome, 
and the uterus restored itself in due time. 



100 



RETROVERSION OF THE UTERUS. 



Denman has some very useful remarks upon this subject, which I 
would recommend to be studied — he advises the employment of the 
flexible male catheter; in this I heartily concur: he also cautions 
against any attempt to display dexterity, by the quick introduction of 
this instrument ; and recommends the slow and cautious use of it — he 
also proposes pressure upon the abdomen, to promote the discharge 
of the urine ; I may, however add, that not only the introduction of 
the catheter should be slow, but the drawing off the water also — for 
I am certain I once saw death follow the sudden discharge of this 
fluid.* 

285. To overcome the second difficulty, injections should be thrown 
up the rectum, if practicable ; but which, it must be confessed is some- 
times impossible — we can succeed, however, with the elastic gum 
catheter of a large size,f when the common means have failed: the 
injection should consist simply of a table-spoonful of common salt 
and a pint of water. A few hours before we attempt the reduction, 
small but repeated doses of the sulphate of magnesia may be given ; 
provided the stomach is not distressed by vomiting or severe 
nausea. 

286. The third difficulty which may oppose us, is the violent and 
involuntary efforts to bear down, to which the woman is excited by 
the presence of the hand within the vagina — this is decidedly the 
greatest trouble we meet with in ordinary cases — for we may be foiled 
in our attempts at reposition, from this cause, though the emptying of 
the bladder and rectum should not have been found troublesome. 
To overcome this opposition, experience has repeatedly taught me 
the efficacy of bleeding to fainting, or near to it. 

287. When we have determined upon the bleeding, we should 
be prepared, beforehand, to take advantage of the deliquium the mo- 
ment it occurs ; as its continuance is transitory — the bed should be 
prepared in such a manner, as will allow the patient to lie upon her 
back, with the perinaeum free from the edge of the bedstead, and her 
shoulders a little depressed — some protection should be placed be- 
tween the back of the woman and edge of the bedstead, that she may 
receive no injury from its hardness : the parts should be well lubri- 
cated with hog's lard, oil, or a strong mucilage of flaxseed — a chair 
should be placed for each foot to rest upon ; and these supported by 
two assistants. The position is the same, as recommended for 
" turning," &c. (See chap, xviii. sect, i.) 

288. When every thing is in readiness, the arm should be tied up, 
and the patient made to stand near the bed ; a large orifice must be 
made, and blood drawn until faintness is induced — when this happens, 

* This is absolutely necessary, as the efforts to aid the discharge of the urine are 
such, as would most probably prevent the restoration of the fundus. 

t There has lately been invent d a forcing syringe, by which almost any quantity 
can be pumped into the colon. In cases like this, it might be well to throw into the 
bowels such a quantity of warm water or flaxseed tea, as will cause, from its bulk, a 
discharge from the rectum. A large flexible gum elastic tube, can, we believe, with 
care > be always introduced to the necessary height in the bowel, in these cases. 



RETROVERSION OF THE UTERUS. 101 

the arm can be secured, and the woman placed as just directed — the 
hand, after being well lubricated, should be passed into the vagina, 
in a state of supination ; the fingers retracted in such a manner, as to 
form a straight line at their extremities ; they must then be gently 
pressed against the base as it were of the tumour found within the 
vagina, so as to move it backwards and upwards along the hollow of 
the sacrum, until the mass shall reach above the projection of this 
bone : when thus far, the hand may be withdrawn ; and a pessary or 
a piece of sponge should be introduced of a proper size : the woman 
must remain quiet in bed for three or four days, the urine, for this 
period, should be drawn off as often as may be required ; and the 
feces evacuated by injections. 

289. The last of our embarrassments arises from the size of the 
uterus being equal to, or greater than the opening of the superior 
strait; this will be confessed to be one of much moment and interest 
— yet, I trust it is not beyond remedy — I believe that the plan just 
suggested, might succeed even here ; but I confess it wants the test 
of experience. It should, from every consideration, be tried before 
severer means be adopted ; for if it fail, we lose nothing. But sup- 
pose it fail, what is to be done ? Three modes of operating present 
themselves in this dilemma. 

290. First, to confide entirely in the resources of nature, as recom- 
mended by Dr. Merriman. 

291. Secondly, to attempt to provoke abortion, by rupturing the 
membranes, through the os tincse. 

292. Thirdly to puncture the uterus through the rectum, as ad^ 
vised by Dr. Hunter, or through the vagina, as practised by M. 
Jourel. 

293. With respect to the first, there is, from all I can learn, but 
little temptation to trust to it. See strictures on Dr. Merriman's opi- 
nions, in "Essays on various Subjects connected with Midwifery," by 
the author, p. 291. 

294. The second, if practicable, would unquestionably be the 
mildest and safest ; but its success, (so far as I can at present de- 
termine,) must be very uncertain, or it may be always impracti- 
cable." 1 

295. The third alternative has been condemned by some of the 
British writers ; but, as it would appear, without sufficient reason ; 
since M. Jourel succeeded recently in a case, the details of which are 
highly interesting and instructive, and should be carefully consulted 
by all who practise midwifery. f We find also in the Ed. Med. and 
Sur£. Journal, for April, 1830, that this operation has also been per- 
formed with success, by Mr. Beynham. 

296. In the anteversion, the fundus of the uterus is thrown for- 
ward, and downward ; so that it presses immediately against the pos- 

* See Essays on various Subjects, &c, by W. P. Dewecs, p. 287. 
t Dictionnaire des Science Medicales, Vol. IX. p. 31. 

10 



102 OF THE OBLIQUITIES OF THE UTERUS. 

terior and inferior portions of the bladder, while its neck is carried 
backward towards the projection of the sacrum. In this displacement, 
the symptoms are said to be less severe than with the retroversion — 
the tumour being anterior, and the neck of the uterus posterior, will 
readily distinguish the one from the other — I have never seen a case 
of this kind so strongly marked as to leave no doubt of its existence 
— I was once called to a patient in whom I suspected it had taken 
place ; but it was in a partial degree, if at all — the symptoms were 
distressing, but eventually relieved by the use of the catheter and 
anodyne injections. This disease has been mistaken for stone in the 
bladder, agreeably to Luret, (Jour, de Med. Vol. IV.) and the ope- 
ration of lithotomy absolutely performed.* 

297. When the unimpregnated uterus is retroverted, it creates fewer 
inconveniences than when impregnated — the indications are precisely 
the same — the mode of reduction is also similar. This can sometimes, 
however, be effected without the introduction of the hand, by the 
proper application of the fingers alone — I succeeded in this way, in 
two instances of this kind of retroversion ; both of w T hich, however, 
were very recent w T hen the attempt was made. 

Sect. III.— -Of the Obliquities of the Uterus. 

298. The inconveniences arising from these species of displacement 
of the uterus, are sufficiently serious to merit an exposition of their 
mechanism. When we consider the globe-like form that the uterus 
constantly presents during its development ; when we recollect how 
feebly it is supported by its ligaments ; and bring to mind the angle 
at which it must pass through the superior strait, we shall not be at 
all surprised to find it fail to maintain such a situation in the abdomen, 
as will enable the axis of its fundus, and that of the superior opening 
of the pelvis exactly to coincide. If we add to this, the peculiarity 
of conformation of several of the parts of the pelvis, and of its more 
immediate dependencies ; and the influence these have upon this organ 
during its ascent into the abdomen, we shall soon be convinced of 
almost the impossibility of its centre preserving a correspondence with 
that of the pelvis — hence, the constant presence of obliquity, in one 
form or other, in almost every pregnancy. 

299. The obliquities of the uterus maybe divided into three kinds : 
— 1st. The right lateral obliquity: 2d. The anterior obliquity; 3d. 
The left lateral obliquity, f In the first, the fundus of the uterus is 

* Notwithstanding Dr. Ingleby advocates, and apparently believes, in Dr. Merri- 
man's notions on the subject of retroversion ; and his declaration, that they will be 
adopted by the profession, mauger " Dr. Dewees' severe criticisms to the contrary," 
we remain unconvinced ; and shall remain so, until Dr. M. or Dr. I. furnishes the pub- 
lic with other arguments, or less disputable facts than they have hitherto done. We 
are always sorry to differ from gentlemen of the high standing, and acknowledged 
talents that these gentlemen so justly merit, but we feel we have no right to yield our 
opinions, unless they are proved to be wrong, by additional facts, or lucid argument. 

t Leveret has added a fourth — this consists of a falling of the womb backwards 
upon the lumbar vertebra) ; but that this obliquity may take place, it is necessary that 



OF THE OBLIQUITIES OF THE UTERUS. 103 

found more or less inclined to the right portion of the abdomen, and 
its length and departure from a vertical line can readily be detected 
by the hand placed upon it — and when this inclination is excessive, 
as it sometimes is, it may be observed by the eye, especially if the 
"woman be viewed from behind. This species is by far the most fre- 
quent ; owing to the constant presence and influence of certain deter- 
mining causes ; 1st. The manner in which the rectum descends in the 
hollow of the sacrum ; the rectum, in passing into the pelvis, does not 
preserve the centre of this bone, but inclines rather to the left portion 
of it ; of course, when filled with feces, it will occupy a part of the 
lower strait ; and consequently, will give an inclination to the uterus 
towards the right side; 2d. The sigmoid flexion of the colon, from 
its position, and almost constant distention, will aid by its impulses 
the already inclined fundus, in the same direction; and if we add, 
3d. The round projection offered by the salient portion of the sacrum, 
we shall be at no loss to determine why the right lateral obliquity is 
of all the most frequent. It would not, however, be correct to sup- 
pose, that the os uteri would be found always in an exact line with the 
fundus — I have known a number of exceptions to this. 

300. In the second or anterior obliquity, the fundus of the uterus 
continues to advance in the direction it received when passing through 
the superior strait — when treating on the pelvis, I mentioned that 
this was at an angle of between thirty and forty degrees ; consequently 
the fundus would carry the abdominal parietes before it in all in- 
stances, were not a counteracting influence found in the firmness and 
elasticity of these parts — therefore the anterior obliquity will be, in 
frequency and extent, in exact proportion to the want of resistance 
from these parietes ; hence it is rare in a first pregnancy,* owing to 
the firmness of the abdominal integuments ; and of very frequent oc- 
currence in subsequent ones. Sometimes the extent of this obliquity 
is almost incredible, especially in small women who are much upon 
their feet ; and in those who have a deformity of pelvis. In this ob- 
liquity there will be more or less correspondence of the axes of the 
fundus and mouth of the uterus, as this deviation may be more or less 
excessive. 

301. This obliquity is almost always a source of great inconve- 
nience to the woman even before labour ; for after the seventh month, 
the fundus is so depending, and so much in advance, as to alter the 
usual centre of gravity ; and the woman, is, when either walking or 
standing, obliged by constant exertion, to make herself a new one. 
This is accompanied often, and more especially towards the latter 
period of pregnancy, with severe pain in the back, loins, and hips ; 
together with a forcing and bearing down ; urging the woman to make 
w r ater, or to go to stool. I have frequently known these symptoms so 

this column be flexed outwards — a deformity may give rise to this variety of obliquity, 
but cannot happen without it : it is therefore not necessary to notice it farther. 

* It may be proper to observe, I have never seen it take place in a first pregnancy. 
I have seen one exception since the above was written. 



104 QF THE OBLIQUITIES OF THE UTERUS. 

severe as to oblige the woman to keep her bed, that she might enjoy 
a moment's respite from their urgency — this especially happens to 
short women who have had a number of children, and who have al- 
ways had severe labours. 

302. I have been frequently consulted for this very unpleasant 
situation of the uterus — but there is but one remedy for it, so far as 
I know ; namely, to support the body and fundus, as much as may 
be, by a proper bandage, or dress — the most effectual I have em- 
ployed is, a pair of drawers with a waiscoat attached to it which will 
lace behind. The waistcoat need not reach but a little above the 
umbilicus ; but it must be maintained in its situation by a support from 
above by a pair of properly adjusted suspenders. This dress should 
be put on in the morning before the woman rises upon her feet ; and 
when it is about to be applied, the fundus must be raised, by the 
hands of the patient being placed under it, and lifted as it were up- 
wards ; while the back part of the waistcoat is laced sufficiently to 
give support to the uterus, when left to itself. By this simple con- 
trivance, I have seen women become active, and capable of attending 
to their domestic concerns, who previously to its application, were 
confined to their beds. 

303. The third or left lateral obliquity, is so rare as to scarcely 
merit mention ; and especially as the inconveniences arising from it 
must be nearly the same as from the right lateral ; and the mode of 
remedying it also the same, mutatis mutandis. 

304. It is of much practical importance, that these different devia- 
tions be known, as they are for the most part of easy remedy ; but 
when not, much suffering is experienced. Thus, in the right lateral 
obliquity, placing the woman upon her left side, will very frequently 
be all that is required ; but should this position not bring the os uteri 
to the axis of the pelvis, we must aid it by the introduction of a finger 
within it, when it is either well dilated or easily dilatable; and this, in 
the absence of pain; when hooked it must be gently drawn towards the 
symphysis pubis, and retained there, until a pain ensue ; should the 
contraction of the mouth of the uterus offer much opposition to the 
force which is to keep it at the symphysis, as just mentioned, we 
should gradually yield to it; but need not withdraw the finger-^when 
relaxation has taken place, we again conduct the os uteri to the place 
before indicated ; and maintain its position there, unless again forced 
to relax our effort for the reason just stated---in this manner we alter- 
nately retract, and relax, until we establish a correspondence between 
the axes of the fundus, the mouth of the uterus, and the pelvis: when 
this is accomplished, we will find the labour advance with more rapi- 
dity, and with less pain. 

305. In the second, or anterior obliquity, the same indication pre- 
sents itself; namely, to procure a proper relation between the axes of 
the uterus and pelvis ; but the mode of fulfilling it is different — in this 
case we place the woman upon her back; and at the time, and under 
the circumstances pointed out above, (304 3 ) we, with the point of the 



OF THE OBLIQUITIES OF THE UTERUS. 105 

linger, search for the os uteri towards the projection of the sacrum. In- 
cases of extreme obliquity, it is oftentimes difficult to reach the os uteri 
by the ordinary mode of examination ; when this happens, the pendu- 
lous belly should be raised and supported by an assistant, with a view 
to depress the os uteri — should this not succeed, and should the pains 
be brisk, the head will be found to sink lower and lower in the pelvis, 
covered by the stretched anterior portion of the uterus. If advantage 
be not now taken to introduce the hand to restore the os uteri to the 
proper axis of the pelvis, much suffering must be endured and much 
risk incurred by permitting the head to descend, covered by the 
uterus. 

306. Whenever the os uteri cannot be reached by a well-directed 
search in the ordinary way, we must introduce the hand well lubri- 
cated,* so that its palm may be next to the distended uterus ; a finger 
should then be made to reach up to the neighbourhood of the projec- 
tion of the sacrum, where,, on some one portion of the uterine globe, 
the os uteri will be detected — when discovered, we should hook it 
upon the point of the finger, (provided it is either dilated or easily 
dilatable, and draw it towards the centre of the inferior strait — when 
it has followed so far, the hand may be gently withdrawn, (but not 
the finger from the os uteri,) and the uterus detained there, until the 
proper direction of the forces, and the axis of the uterus, are in cor- 
respondence. By this simple proceeding much time and suffering 
are saved; and, in some instances, I am well persuaded that much 
risk is prevented. Baudeloeque has most satisfactorily illustrated the 
advantage of judicious interference, and the consequences of the neglect 
of it, by the recital of two opposite cases, to which I would refer the 
reader with much advantage to himself. 

307. Chapman also relates a somewhat similar case ; that is, labour 
was long protracted in consequence of the very posterior situation of 
the os tincse. He introduced his finger, drew it forward, and esta- 
blished a proper correspondence between the direction of the uterine 

*■ I have seen, wiih much pleasure, in the July and August Nos. of the Lond. Med. 
and Chir. Review, a most liberal examinaiion of this work. But the author of the Re- 
view seems not to have clearly understood this par. (30G) as he cautions against the 
introduction of the hand, for the purpose of rectifying the bad position of the os uteri; 
. it would be a difficult or painful attempt to do so with a first child. I agree, 
under such a circumstance,, it might be inconvenient; but the obliquity now under 
consideration, I have never known to take place in a first pregnancy but once; con- 
sequently the objections cannot be constantly valid; yet, were it even to happen in a 
first labour, I would unquestionably pursue the same conduct, from a conviction that I 
should expose my patient to the lesser evil. 

Let me, however, be clearly understood to mean, that I would introduce the hand, if 
the labour from its duration and force, gave me reason to believe, that the want of pro- 
the presenting part was owing to the constrained position of the uterus; and 
when the os uteri cannot be reached by ohe ordinary mode of examination ; consequently, 
when it did not correspond with the axis of the pelvis. This I confess to be a situa- 
tion of rare occurrence, yet it is one to be met with, as I can testify, and it should he 
provided for, if it occur: for if the os uteri be not within reach by a common search, 
and it shall give rise to an opera' ion like the one to be related presently, would it not; 
then be more than fastidious, to withhold a proper examinaiion, from a mere repugn 
nance to introduce the hand into the vagina, if the labour were even a first one, 

10* 



106 OF THE OBLIQUITIES OF THE UTEKUS. 

forces and the axis of the os uteri. Chapman, however, does not 
appear to have understood his own case ; he supposed the delay was 
occasioned by the os uteri being but little opened. He attempted its 
dilatation ; and this attempt brought the opening of the uterus to cor- 
respond with the axis of the vagina, by which means the woman was 
speedily delivered (Treatise on Midwifery, p. 15.) 

308. I must take this opportunity to notice a few remarks made by 
Mr. North upon this point, in the London Medical and PhysicalJour- 
nal, for September,- 1827. Mr. North seems averse from pursuing 
the plan I have proposed for the relief of the anterior obliquity of the 
uterus. He objects to the plan, because he has " known inflammation 
of the uterus produced by the rough and repeated efforts of young 
practitioners to 'hook 5 down the os uteri." Now, this certainly is 
only condemning the abuse of the method; which should never be 
considered as a valid objection against the employment of a well-di- 
rected one. I can with very great confidence declare, I have never 
known even pain excited when this simple operation has been per- 
formed by myself; nor can I ever believe that any inconvenience 
would follow the plan, if properly performed by any one else. If we 
are to hesitate to recommend useful practical operations, because they 
may be illy performed by the careless or the ignorant, we should at 
once banish from medical science its best resources, and its greatest 
triumphs. 

309. Mr. North most flatteringly expresses his entire belief, that I 
could have recourse to the plan recommended without injury to my 
patient : now, if this be true, it must necessarily follow, that it is not 
essentially dangerous; and if the directions laid down be strictly fol- 
lowed, I am persuaded it cannot be even contingently so. I agree 
perfectly with this gentleman, and with Dr. Denman, whom he has 
cited to strengthen his objections, that time may sometimes effect 
delivery in the obliquity in question, without seriously injuring the 
patient ; but it cannot do this without causing long and severe suffer- 
ing. It is not denied by Mr. N. that this situation of the uterus may 
create some embarrassment, if unreduced; as he.recommends, for this 
purpose, that the woman should be placed upon her back, as I have 
done ; but he makes no provision in case of failure from the change 
of position except that time will overcome it, if a sufficient quantity 
of it be given. 

310. In the case under consideration, the question is not, whether 
the unaided powers of the uterus may not eventually overcome the 
difficulty caused by the anterior obliquity of this organ. The true 
one is, whether we cannot, most profitably to the mother and child, 
interfere. As far as my own experience goes, I can most conscien- 
tiously answer this in the affirmative. This was the opinion of Bau- 
delocque, from whom I learn this treatment; and he is certainly au- 
thority equal to Dr. Denman. 

311. Mr. North remarks as follows, upon a part of the plan in 
question: "According to the directions of Dr.. Dewees,, we axe not 



OF THE OBLIQUITIES OF THE UTERUS. 107 

to remove the finger from the os uteri, ' until the proper direction of 
the forces and the axis of the uterus are made to correspond.' It 
must obviously, then, be impossible for the practitioner to determine 
whether the favourable change in the position of the parts is the result 
of his assistance, or the continued uterine efforts which have been 
going on." I would inquire, in what the difficulty in this instance 
lies. Can it be imagined, that a practitioner, especially one who ap- 
pears to be so judicious as Mr. N., should for a moment be at a loss, 
to what cause to attribute the change in the direction of the axes; the 
descent of the head ; and the rapid termination of a labour, after es- 
tablishing a correspondence between the mouth of the uterus, and the 
axis of the upper strait ? Previously to the interference, hours had 
been fruitlessly spent ; and the os uteri was mounted high before the 
projection of the sacrum; and though soft, and yielding, no exertion 
of the uterus could make the head engage in it, and consequently 
could not descend through it ; but in a few moments, all these un- 
pleasant conditions are favourably changed, by merely drawing the os 
uteri to the centre of the pelvis, (316, 317.) Yet we admit that the 
head may be forced lower into the pelvis by the long-continued con- 
tractions of the uterus ; but it must be recollected, when this is the 
case, it makes its way by stretching the anterior portion of this organ, 
(305,) a circumstance, in some instances, highly dangerous, and not 
by passing through the axis of the mouth. (Baudelocque, loc. cit.) 

312. But I would ask in all sincerity, what is to be apprehended, 
if the rules I have laid down, and the circumstances, under which it 
is directed we should act, be strictly observed? we cannot see either 
difficulty or danger ; and we must insist, that in the cases in which 
it is necessary to interfere, it is a duty to do so; for we hold it to be 
a sound principle, that whenever we can spare an hour's, or even less 
of unnecessary pain, it is right, nay it is obligatory upon us to do so. 
We are not to permit a patient to suffer a great positive evil, from the 
apprehension of a small contingent one. 

313. We must therefore insist, that though nature unaided may 
struggle through a difficulty, it is not right to permit her to do so, if 
we can, by a timely and judicious interference, abridge her efforts. 
Besides, it is not a necessary consequence, that nature can perform 
the task assigned her, with entire safety to the patient, if even time 
be given ; for her efforts are far from being always crowned with suc- 
cess, or always free from hazard. I would therefore still insist, be- 
cause it so entirely comports with often-repeated experiment, that it 
is the duty of the accoucheur, in cases of anterior obliquity, always to 
act as has been directed, (306) whenever the natural forces do not, in 
a reasonable time establish a correspondence between the axis of the 
pelvis, and of the os uteri, and when the latter is either dilated, or 
easily dilatable. And we must farther insist, that no injury can pos- 
sibly arise from this simple operation, if it be any way carefully per- 
formed ; but by employing it, much time, more suffering, and this 
without risk, may be saved the patient. For though it has chanced 



108 OF THE OBLIQUITIES OF THE UTERUS. 

to be the good luck of Mr. N. not to have witnessed "a case in which 
the unassisted efforts of nature have not terminated the labour in a 
favourable manner," yet it has not always fallen to the lot of others 
to have seen such instances. 

314. Indeed, Mr. N. indirectly confesses he has never seen the 
case for w T hich we recommend interference ; he consequently cannot 
be a competent judge of the necessity ; he therefore should not con- 
demn those for acting, who have been under the necessity to do 
so, especially as he justifies the operation under the circumstances for 
which we direct it, in the following words : " But, however desirable 
it may be that the process of labour should not be improperly inter- 
fered with, it is equally necessary that we should not withhold our aid 
when it is really required. If it should happen that the uterine efforts 
do not gradually bring the os uteri into the direction of the axis of the 
inferior aperture, and that the head of the child is forced down by each 
pain, with the body of the uterus expanded over it, it would then be 
proper for the practitioner to endeavour to place the parts in a more 
favourable situation, by the practice recommended by Dr. Dewees.' 7 
Now, this confession is all that is required ; for we only direct inter- 
ference in the precise case stated by Mr. N. I would ask, then, what 
is there to condemn, in what I have said upon this subject? for I have 
advised nothing, in which Mr. N. has not entirely acquiesced, by the 
concession in the last quoted sentence. 

315. Within my own knowledge, this ease has been mistaken for 
an occlusion of the os uteri; and upon consultation, it was determined, 
that the uterus should be cut through to make an artificial opening for 
the fcetus ; they thought themselves justified in this opinion, first, by 
no os uteri being discoverable by the most diligent search ; and se- 
condly, by the head being about to engage under the arch of the pubes 
covered by the womb ; accordingly, the labia were separated, and the 
uterine tumour brought into view : an incision was made by a scalpel 
through the whole length of the exposed tumour, down to the head of 
the child — the liquor amniiwas evacuated, and in due course of time, 
the artificial opening- was stretched sufficiently to give passage to the 
child; the woman recovered; and, to the disgrace of the accoucheurs 
who had attended her, was delivered, per vias naturales, of several 
children afterwards — a proof that the operation was most wantonly 
performed. 

316. I have found, more than once, in cases of extreme anterior 
obliquity, that it is not sufficient for the restoration of the fundus, that 
the woman be merely placed upon the back : for w T e are also obliged 
to lift up, and by a properly adjusted towel or napkin, to support the 
pendulous belly, until the head shall occupy the inferior strait. To 
illustrate this, I will relate one of a number of similar cases, in which 

this plan was successfully employed. Mrs. , pregnant with 

her seventh child, after the seventh month was much afflicted with 
pain, and the other inconveniences, which almost always accompany 
this hanging of the uterus ; and was obliged to wear the jacket recom- 



OF THE OBLIQUITIES OF THE UTERUS. 109 

mended above, from which she experienced much relief. She was 
taken with labour pains on the morning of the 10th of October, 1820; 
I was not sent for until about noon — the pains were frequent and dis- 
tressing, and upon examination per vaginam, the mouth of the uterus 
was found near the projection of the sacrum, and dilated to about the 
size of a quarter of a dollar ; it was pliant and soft ; and during a 
pain, the membranes were found tense within the os uteri ; but did 
not protrude beyond it. 

317. As this was the first time I had been called to attend this pa- 
tient, and the history she gave of her former labours represented the 
abdomen to be equally pendulous in each, with the exception of the 
first ; I waited several hours, (the patient being on her left side,) for 
the accomplishment of the labour. During the whole of this period 
the head did not advance a single line, nor could it, as the direction 
of the parturient efforts carried it against the projection of the sacrum. 
I had several times taken occasion to recommend her being placed 
upon her back; but to this she constantly objected, until I urged its 
absolute necessity — she at length reluctantly consented. When upon 
her back, it was found that the os uteri was not sufficiently advanced 
towards the centre of the superior strait, the abdomen was, therefore, 
raised, and a long towel placed against it ; and it was kept in this 
situation, by its extremities being firmly held by two assistants — at 
the same time I introduced a finger within the edge of the os uteri, as 
directed above, (304,) and drew it towards the symphysis pubis, and 
then waited for the effects of a pain — one soon followed, and with 
such efficacy as to push the head completely into the inferior strait ; 
and by three more, it was delivered. In this case I have every rea- 
son to believe, that many hours more would have passed without pro- 
fit, had I not insisted upon the change of position ; and, in my opinion, 
it most decidedly proves the importance of correct principles in the 
art of midwifery. See Baudelocque. 

318. It might be considered as highly useful in such cases, that 
the woman lie as much as possible upon her back, even from the com- 
mencement of the labour, as it w r ould certainly contribute to the res- 
toration of the displaced uterus : it is, moreover, very important in 
such instances that the bowels be opened either by some gentle me- 
dicine, or by an injection, that no accumulation of feces may take 
place in the rectum. 



110 OF THE TERM UTERO- GESTATION. 



CHAPTER X. 

OF THE TERM OF UTERO-GESTATION. 

219. The time a foetus resides in utero is not precisely determined 
by physiologists, even when the woman is placed under the most 
favourable circumstance for ascertaining it. It seems, however, from 
the best calculations that can be made, that nine calendar months, or 
forty weeks* approach the truth so nearly that we scarce need desire 
more accuracy, could it be obtained. There are unquestionably many 
causes which may provoke the uterus to contraction, before the full 
period of utero-gestation, or before it might take place spontaneously ; 
there may also be some which may procrastinate the common period. 
The frequency of abortion, and the occasional occurrence of premature 
delivery, sufficiently prove the first ; and the very much more rare, 
but, nevertheless, well authenticated instances of prolonged gestation, 
put the latter almost beyond dispute. But of the latter I shall again 
have occasion to speak more at large, (325, &c.) Of the premature, 
however, I may remark, that I have known several instances where 
labour habitually occurred before the full period ; with one lady it 
always happened at the seventh month ; and in two others, it regularly 
took place at the eighth month of pregnancy. And of the protracted, 
I have known still more instances, where every circumstance and cal- 
culation rendered it nearly certain that the children were carried ten 
months, or even a little beyond it. 

320. We have no certain mark to detect the instant at which con- 
ception takes place ;f and consequently, w T e cannot ascertain, with 
absolute precision, the exact extent of time the foetus resides in utero. 

The cessation of the menses, and quickening, are the most com- 
mon foundations to calculate from : but these must necessarily be 
liable to considerable variation ; since, perhaps, it is not erring greatly, 
to say that the woman is liable to conceive, at any part of the men- 
strual interval : and that she may quicken at various periods of gesta- 
tion. It is generally supposed, however, that the most favourable in- 

* We are certain that it would be more definite, if not more accurate, to specify the 
period of gestation by days, were this more practicable than the other method ; but 
there must always be a starting place and the uncertainty of that place, to start from, 
is just as uncertain, as when we enumerate by weeks or calculate by months. 

t There are many popular errors upon this subject, to which it may be well to say 
in contradiction of them, that our experience furnishes no certain mark, by which the 
moment conception takes place is to be distinguished. All appeals by the woman, to 
particular sensations experienced at the instant, should be very guardedly received ; 
for we are certain they cannot be relied upon ; for enjoyment and indifference are 
alike fallacious. Nor are certain nervous tremblings, nausea, palpitation of the heart, 
the sensation of something flowing from them during coition, &c, more to be relied 
upon. 



OF THE TERM OF UTERO-GESTATION. Ill 

stant is, immediately after the catamenial evacuation had ceased ; per- 
haps this is so, as a general rule ; but it is certainly liable to excep- 
tions. The uncertainty of the moment at which conception takes 
place, will always embarrass calculation ; since a latitude of from two 
to three weeks must be permitted. 

321. But opportunities have occurred where the utmost accuracy 
must have prevailed : one presented itself to my notice, many years 
ago. The husband of a lady who w T as obliged to absent himself many 
months, in consequence of the embarrassment of his affairs, returned 
one night clandestinely; his visit being only known to his wife, her 
mother, and myself. The consequence of this visit was the impreg- 
nation of his wife. The lady was at this time within a week of her 
menstrual period ; and as this did not fail to take place, she was led 
to hope she had not suffered by the visit of her husband. But her 
catamenia not appearing at the next period, gave rise to fear, that she 
had not escaped ; and the birth of a child, nine months and thirteen 
days from the time of this clandestine visit, proved her apprehensions 
too well grounded. 

322. This case is remarkable for two facts : one that a woman in 
perfect health, and pregnant with a healthy child, may exceed the 
period of nine months, by several days ; the other is, that a woman 
may become impregnated just before her menstrual discharge is about 
to take place, and not have it interrupted — and also, it seems, that a 
check is not immediately given to the catamenial flow 7 , by an ovum 
becoming impregnated. This fact has perhaps frequently obtained ; 
or at least more frequently than is imagined, and has thus created no 
inconsiderable error in calculation. Desormeaux relates, that " a 
lady, the mother of three children, became insane. Her physician 
considering that child-bearing might have a beneficial influence on the 
mental disease, permitted the husband to visit her, under condition 
that it should be once only, and at the distance of three months, in 
order that if conception took place, there might not be a risk of abor- 
tion, from farther intercourse. The physician and attendants made 
an exact note of the time when the husband was permitted to visit his 
lady. When symptoms of pregnancy appeared, the visits were ab- 
solutely and totally discontinued. The patient was necessarily 
watched by the female attendants required for her malady, and was, 
moreover, a lady of the strictest principles of morality. She was de- 
livered at the termination of nine solar months and a fortnight, of a 
small child, of which she was delivered by Desormeaux himself." 
(London Medical Gazette, Dec. 12, 1829, p. 344.) 

323. As we are entirely unacquainted with the causes which excite 
contractions in the uterus for the purpose of expelling its contents at 
the expiration of nine months or thereabouts, so we remain ignorant 
of the conditions, both on the part of the uterus and of the child, to 
make these causes available— all w r e at present know upon the subject 
is, that it is an established law ; but it is every way certain that this 
law arises from conditions, of which we are altogether uninformed. 



112 OF THE TERM OF UTERO -GESTATION. 

(See par. 325, and following.) As the period of incubation is im- 
mutable, in every particular species of birds, we have some reason to 
believe, that the development of the foetus has some agency in deter- 
mining the period ; but of this, we can say nothing positive, as so 
many apparent exceptions present themselves. 

324. Many ingenious hypotheses have been proposed to explain 
this interesting phenomenon ; but all of which fail to be satisfactory, 
from the existence of one fact — ^namely, that in cases of extra-uterine 
conceptions, the uterus, at the expiration of nine months, is as cer- 
tainly thrown into painful contractions, of shorter or longer conti- 
nuance, as if the foetus had resided within its cavity. And to these 
we may add, that in the few cases of very extended gestation, the 
same thing has as constantly occurred, if these cases have been faith- 
fully related; and as far as we can judge upon this subject, there 
does not appear to be any rational ground to suspect their fidelity. 
Now, these things being true, they must at once put to flight the 
ingenious speculations of the theorist. 

325. Be the exact period when it may, sufficient has been ascer- 
tained to fix the common one, at about nine months ; and in making 
calculations, it is always best to allow a little latitude beyond the 
time which the mere stopping of the menses would indicate ; for as a 
general rule it will be found, that more women are impregnated, a 
few days after this evacuation, than at any other period. 

326. We are aware that much doubt is entertained, and much 
wit has been expended, upon the testimony which' accoucheurs give 
upon the absolute duration of human gestation ; and especially since 
the discrepant evidence given by seventeen professional gentlemen, 
in the Gardner Peerage cause. But it should be borne in mind, that 
doubt is not proof; nor is wit, argument; consequently, neither 
should be permitted to have an undue influence. Yet we are dis- 
posed to grant, that all testimony that contravenes the general laws 
of nature in relation to this subject, should be admitted with great 
caution : and only after a strict examination. 

327. For, were the plea of the possibility of an unusual extension 
of the term of utero-gestation made a common one, or admitted 
with too much facility, the consequences would be as extensive as 
mischievous. But this cannot very well happen under its present 
limitations; as public opinion, and supposed correct observations, 
are so inveterably fixed upon this point, that little danger can be 
apprehended from an occasional, and a well qualified admission of it. 

328. Nature, for the most part, is pretty steady and uniform in her 
operations ; and perhaps in none is she more so, than in her general 
scheme of impregnation. Yet it is notorious, even in this, her 
favourite process, that she is occasionally so vague, and sometimes 
so whimsical, that perhaps few instances exist of absolute uniformity. 
These remarks will apply with much force, to the subject in question, 
if any reliance may be placed upon circumstances purporting to be 



OF THE TERM OF UTERO-GESTATION. 113 

facts, or upon human testimony ; or at least, as far as facts and testi- 
mony are concerned, with the events connected with impregnation, 
in the present state of society. 

329. How much more uniform nature may be in her operations 
in savage life, we have no facts to direct us, which can be unhesita- 
tingly received ; nor would it perhaps be essential to the investiga- 
tion of the present question, as it could not have a bearing upon the 
conduct of females in civilized life; though it would be confessedly 
curious, if not highly useful, to ascertain the degree of her uniformity 
or the extent of her aberrations. 

330. We have already confessed, that we are altogether ignorant 
of the natural cause which calls the uterine fibre into action at about 
the end of the ninth calender month ; so, we cannot deny but that the 
operation of this cause, be it what it may, can be suspended in some 
instances, either by a diminution of the force of the cause, or by some 
change in the disposition of the uterus itself, to be acted upon beyond 
the common or ordinary limit assigned for human gestation. That 
such departures from the general rule do take place from time to time, 
we have not the slightest doubt ; and we believe this, with the more rea- 
diness, because it does not appear to be confined to the human species. 
For if we are to believe Tessier, he found as great departures from the 
ordinary- rule, among several of the inferior animals to which his expe* 
riments were directed, as is declared to occur with the human female. 

331. As the experiments of the naturalist just mentioned, are highly 
curious, and not very generally known, we will employ them in detail; 
and at the same time consider them as furnishing an argument from 
analogy, in favour of the opinion we are attempting to support.* 

332. " In live hundred and seventy-five cows, twenty-one calved 
between the two hundred and fortieth and two hundred and seven- 
tieth days, average two hundred and fifty-nine ; five hundred and 
forty-four between the two hundred and seventieth and two hundred 
and ninety-ninth days, average two hundred and eighty-two ; and ten 
between the two hundred and ninety-ninth and three hundred and 
twenty-first days, average three hundred and six ; average of the 
whole, two hundred and eighty-two days ; so that from the shortest 
to the longest period, there is a difference of eighty-one days ; that 
is, more than one-fourth of the average time." 

333. " In two hundred and seventy-seven mares, with foal for the 
first time, twenty-three foaled between the two hundred and eighty- 
seventh and the three hundred and twenty-ninth days, average three 
hundred and twenty-two days; two hundred and twenty-six, between 
the three hundred and twenty-ninth and three hundred and sixtieth 

* Dr. Beck appears unwilling to make the conclusion of Tessier apply to human 
gestation : he says, "These facts certainly go to show that the period of gestation is 
irregular among animals, and should they be verified by succeeding observers, a strong 
argument fr.,m analogy will be famished against its uniformity in the human race. 
It must however be recollected, that, even if perfectly established, it is only a favoura- 
ble, and not a decisive proof." — Elements of Medical Jurisprudence, Vol. I. p. 290. 
11 



114 OF THE TERM OF UTERO-GESTATION. 

days, average three hundred and forty-six ; and twenty-eight between 
the three hundred and sixtieth and four hundred and nineteenth days, 
average three hundred and seventy-two ; average of the whole, three 
hundred and forty-seven days ; difference between the extremes, one 
hundred and thirty-two days." 

334. " In one hundred and seventy mares which had foaled before, 
twenty-eight foaled between the two hundred and ninetieth and three 
hundred and twenty-ninth days ; average three hundred and twenty- 
one ; one hundred and twenty-eight between the three hundred and 
twenty-ninth and three hundred and sixtieth days ; average three hun- 
dred and forty-one ; and fourteen between the three hundred and 
sixtieth and three hundred and seventy-seventh days ; average three 
hundred and seventy ; average of the whole, three hundred and forty- 
one days : so that between the shortest and the longest period there 
w r as a difference of ninety-seven days, more than one-fourth of the 
mean term." 

335. " In nine hundred and twelve sheep, the mean time of gesta- 
tion w T as about one hundred and fifty-one days, and the extreme dif- 
ference only eleven days." 

336. " In tw r enty-five swine, the extremes were from one hundred 
and nine to one hundred and thirty-three days." 

337. " In one hundred and sixty-one rabbits, the extreme terms of 
gestation were from twenty-seven to thirty-five days."* 

338. " Thus, w r e see in the brute a very considerable variety pre- 
vails in the terms of utero-gestation ; and to which, immediate cre- 
dence w T ill be yielded. And though no moral question can arise 
from aberrations in them, they nevertheless furnish us with very inte- 
resting facts, from which most important deductions must be made in 
favour of the occasional extension of the terms of gestation in the 
human female. 

339. In my mind the period of utero-gestation has no absolute 
period ;f and I am of opinion that variations in the term of this pro- 
cess do and w T ill constantly occur ; since, so far as calculation and 
observation have gone, they are in direct opposition to the opinion, 
that the period of human gestation is governed by an immutable 
law. 

340. I have almost satisfied myself, that this process extended in 
one instance, (321,) thirteen days beyond nine entire calendar 
months; and I have had every evidence this side of absolute proof, 
that it has been prolonged to ten calendar months as an habitual 
arrangement, in at least four females that I have attended; that is, 

* See Beck's Elements of Medical Jurisprudence. 

f By this I would be understood to mean, that this proecss is not undeviatingly fixed 
to the lapse of and absolute number of days ; and that the nearest we can approach is 
within a few days of nine months, one way or the other. It is every way probable, 
that certain conditions must obtain, before labour can take place ; and these may de- 
pend upon some physiological harmonies which cannot always be exact ; for the func- 
tions of no one organ in the human body are so regulated in themselves, as to be 
unerringly exact in their performance. 



OF THE TERM OF UTERO-GESTATION. 115 

each of these women went one month lonsrer than the calculations 

o 

made, from an allowance of ten or twelve days after the cessation 
of the last menstrual period, and from the quickening which was 
fixed, at four months. 

341. Besides, a case within a short period has occurred in this 
city, where the lady was not delivered for full ten months after the 
departure of her husband for Europe; yet so well and so justly too, 
did this lady stand in public estimation, that there did not attach 
the slightest suspicion of a sinister cause. 

342. We are fully aware, that all we have said, or could say, on 
this subject, would not amount to legal proof, that the period of utero- 
gestation may exceed by a considerable number of days, or even 
months, the ordinary term, or the period of nine calendar months. 
Yet, we are certain, that a very different opinion would be formed 
out of a court, by the very gentlemen, who so ingeniously contrive 
within it, to create doubts upon this point; for we sincerely believe, 
that the question, when considered in the abstract only, would be 
determined in favour of the possibility of this extension. 

343. To put this question entirely at rest, would require such a 
combination of precautions, and such peculiarity of experiment, as 
to make us believe they will never be executed by design: and we 
must feel how far from being satisfactory they would be, were they 
performed by chance. Therefore at present, we can only rely upon 
such evidences as shall be afforded by females themselves, when 
examined upon the points which have a direct bearing upon the 
subject. 

344. For the most part, in inquiring into this subject, we can 
have imformation but upon three points; namely, the time of cessa- 
tion of the last menstrual period; the time of quickening; and the 
time of delivery; and upon the first two, it is confessed, the woman 
is apt to be rather vague. With a view, however, of arriving at 
some general and satisfactory conclusion, it might be well, that 
every obstetrical practitioner inquire of his patient, whenever his 
attendance is bespoke, for information on the first two points; to 
make a note of the answers he may receive ; and after delivery has 
taken place, to faithfully record that event. In time he will have 
accumulated sufficient data, to warrant a general average of the 
number of days occupied by gestation. But above all, he should 
note, especially in the married woman who may have no sinister 
object in the statements she makes, any remarkable circumstance, 
that may tend to fix the period of conception with more than usual 
precision. In an ample practice, such opportunities every now and 
then occur; and when they do, they should be looked upon as too 
valuable to be neglected, or to be only treasured in the memory. It 
will readily occur to the reader, how such occasions may present 
themselves. 

345. I would not wish to be understood, in what has been said, 
as recommending too much facility of credence in the ipsadixit of 



110 OF THE TERM OF UTERO-GESTATION 

the woman ; on the contrary, from the importance of the subject in 
every point of view, I would advise the utmost caution of investi- 
gation, especially with those who may have made up their minds 
upon either side of the question ; for, agreeably to the old adage, 
" What we wish to be true, we can easily believe." 

346. Dr. Beck, the ingenious and successful author of " Elements 
of Medical Jurisprudence," treats this subject with a levity that 
almost amounts to ridicule. In this we were severely disappointed; 
for we had hoped more from him ; as he has treated so many of 
his subjects with so masterly a hand. In our opinion, he dismisses 
this subject with much more brevity and despatchjhan its claims 
demand ; and this without the use of a single argument, that can be 
called conclusive. 

347. He says, " It is astonishing, and I will add, ridiculous, to 
view the ardour with which writers have advocated this doctrine" 
(of delayed gestation,) Vol. I. p. 292. We would ask why it is 
either astonishing or ridiculous, that writers should engage warmly 
in an inquiry, which involves so many important points as regard 
morals and property? 

348. We admit, that the adoption of every history upon record 
purporting to be a case of extended gestation, would be absurd; or 
to approve of every decision of a court in favour of the woman, 
would certainly be sinning against our better judgment. Yet, we 
hold it would be every way unsatisfactory to the philosopher and 
the philanthropist who might be desirous of investigating this sub- 
ject, to be told, by one of the best medical jurists of the age, that a 
calm and deliberate examination of these histories, (of extended 
gestation,) " must certainly lead to a total disbelief of the doctrine 
of protracted gestation," p. 298. And all this is said, without ad- 
ducing opposing facts, or the employment of any opposite reasoning. 

349. Because an occurrence is rare, it should not be declared 
impossible, especially upon slight, or inadequate ground ; for nothing 
is more common than the abuse of general rules. We do not hesi- 
tate to admit, there is a common or a general period for the termi- 
nation of gestation, in every class of the mammalia ; and with the 
human female, that period is from forty to forty-one weeks; and 
this epoch forms the general rule. This being granted, the question 
must be upon the exception, if the exception exists; or in other 
words, we must inquire, can the term of gestation exceed the ge- 
neral period 1 

350. We must ask, first, do exceptions to the rule just stated, really 
exist ? And secondly, if they do, we must try to ascertain to what 
extent this deviation in utero gestation may have been extended. 

351. First. All writers upon this subject, and even those who are 
unfavourable to the doctrine of protracted gestation, admit there may 
occasionally be a difference of from one to two weeks in the ordinary 
period assigned for this process. This being granted, the question, 
by what law is this variation of period regulated, will naturally pre- 
sent itself. For, if the uterus fail to conform to the law by which it 



OF THE TERM OF UTERO-GESTATIOX. 117 

is said to be governed in the production of labour at the exact time 
fixed upon by some, there must be a cause for the aberration ; and, 
if there be a cause for the aberation, we would ask, how is its limit to 
be determined ? for the cause which is capable of suspending the re- 
gular display of uterine contraction for a week or a fortnight, beyond 
its prescribed time, may, upon certain occasions, be equal to prevent 
it for some time longer. How can we then pretend to fix a limit to the 
suspension, so long as we remain altogether ignorant of the governing 
cause, or of the condition of the uterus, which shall render the appli- 
cation of this cause available ? 

35*2. It is in vain to say, the thing cannot be, because we do not 
understand how it can be ; or, because it appears to violate a law of 
the animal economy. This question cannot be settled by argument ; 
facts alone, must decide it, if it ever be put entirely to rest. We are, 
therefore, not disposed, from what we think we have ascertained upon 
this subject, to be seduced from the opinions we have formed by the 
specious, or perhaps, more properly, the flippant conclusions of Louis; 
and, upon which, Dr. Beck seems willing to rest his cause, p. 297. 

353. Dr. Beck says, that Louis, among other arguments, declares, 
first, " That the laws of nature on this subject are immutable." 
What are we to understand by this assertion ? Is it, that the laws of 
nature are fixed, and without variation in the business of procreation ? 
If they are, as regards the term of utero-gestation, it is the only point 
in which this exactitude exists in the whole work of generation ; and 
for which it would be very difficult to assign an adequate reason ; for, 
" nature works not by partial, but by general laws." It is, as far as 
we can determine, as special a law, that the foetus be developed in the 
uterus, as that it shall not tarry there beyond nine months ; yet we 
find exceptions to this, by its being discovered in the ovarium, tube, 
or abdomen. It is a special law, that the foetus shall have a* head, 
a heart, arms, or legs, yet we every now and then find one deficient 
in one or more of these parts, &c, &c. 

354. Second. " That the foetus, at a fixed period, has received all 
the nourishment of which it is susceptible from the mother, and be- 
comes, as it were, a foreign body." How is this proved ? No proof 
is offered ; there is nothing but a broad assertion which is contradicted 
by almost daily experience, (if we are to understand it as we believe 
Mons. Louis intended it should be, namely, that there is a definite 
and an invariable period, beyond which the foetus cannot be nou- 
rished ; or that the mother could not grant supplies,) if any reliance 
can be put upon human testimony ; or upon facts, which we have 
indisputably witnessed in a number of instances. And if there be 
one single exception, this u immutable law of nature," as laid down 
by him, must fall to the ground. 

3 ies, the foetus cannot be considered, "as it were a fo- 

reign body," so long as it preserves its vitality, and its connexion 
with the uterus. 

356. Third. " That married women are very liable to err in their 

11* 



118 OF THE TERM OF UTERO-GESTATION. 

calculations." Admitted ; but it does not by any means follow, that 
there has been an error in calculation, in every instance purporting to 
be a case of protracted utero-gestation ; consequently, until it be 
proved, that, agreeably to a law of nature, the uterus will not permit 
a foetus to remain within its cavity, beyond a fixed and never varying 
period, we have a right to believe, from both reason and observation, 
that the period commonly assigned, has been very considerably ex- 
ceeded. See Cases I., II. 

357. Fourth. "That the decisions of tribunals, in favour of pro- 
tracted gestation, cannot overturn a physical law." This is also ad- 
mitted; but let it be first proved, that protracted gestation and the 
decisions are at variance with a physical law, before it be considered 
as violated." 

358. Fifth. " That the virtue of females in these eases, is a very 
uncertain guide for legal decisions." Here we are decidedly at 
issue ; for the virtue of the female, in its absolute sense, and practice, 
is one of the most decisive evidences in favour of protracted gestation. 
And this must be admitted, by even our opponents; but to prevent the 
conclusion which would irresistibly follow from this concession, they 
deride its existence either directly or covertly, in every instance pur- 
porting to be a case of protracted gestation. For on the one hand, 
Louis declares the virtue of females to be uncertain guides in legal 
decisions ; and that married females are very liable to error in their 
calculations ; while Dr. Beck more openly decides, that " a calm and 
deliberate examination of these histories, (of protracted gestation,) will 
lead to a total disbelief of the doctrine of protracted gestation.* 

* Dr. Beclc relates the following histories ; we have abridged them, but without 
losing 1 the material points. 

"Bartholin says a young woman declared herself to have been seduced : she was 
strictly guarded after this, and was delivered, sixteen months after of a living child." 
Fodere, Vol. 2, p, 183. 

" In 1638, a woman was delivered of a child, one year and thirteen days after the 
death of her husband. She suffered with severe labour pains one month previously. 
The child's head was without fontanelles. The faculty of Leipsic declared it to be 
legitimate." Valentin's Pandects, Vol. 2, p. 142. 

"A msn died on the 2d of December, 1687, after being eight days in extremis; 16th 
of October following, his wife was delivered of a son. The faculty of Geissen declared 
it to be legitimate." Ibid. 

"Le Seur was struck with apoplexy, May 14th, 1671, and died on the 1 6th. His 
wife had not been pregnant during the six years of their marriige. On the 11th of the 
succeeding September she declared herself pregnan's, and on the 17th of April, 1672, 
(eleven months and four days after his illness,) she was delivered of a son. The rela- 
tives of the husband contested its legitimacy, and obtained a decree in their favour, 
but on appealing to the parliament of Rouen, the cause was decided in favour of the 
widow, on the score of the goodness of character, and on the possibility of protracted 
gestation. The following case is related by JHeister: — A woman was delivered thir- 
teen months after the death of her husband ; the individuals interested were about to 
contest the legitimacy of the child, but were deterred from it by the excellence of her 
character. So convinced was one Christopher Mrsnerus, who had acted as shopkeeper 
during her widowhood, that he married her shortly after, and had two childrenjby her, 
and each of them was born after a gestation of thirteen months." 

"Dulignac testified that his wife with two children went thirteen months and a-half, 
and with a third eleven months. La Clotu e also gave an opinion in favour of the 
widow, and quoted several similar cases from his own observation." 

" Charles , aged upwards of seventy. two years, married Renee, aged thirty 



OF THE TERM OF UTERO-GESTATION. 119 

There are many," he continues, " that evidently bear the impress of 
vice, while the most favourable are so liable to have arisen in error, 
that scepticism must appear unavoidable," p. 298. " This reasoning," 
says Dr. Beck, " appears to me to carry great weight, and Mahon, 
in his chapter on this subject, adds several sensible remarks in con- 
firmation of it. He observes, that ' if the doctrine be true, that the 
children of old people are longer in coming to maturity, it would 
have been confirmed by experience, which it is not.' " Now, we 
cannot perceive any thing very profound in this observation ; on the 
contrary, we think it is marked by much oversight — for it is con- 
tended, by the opposers of the doctrine of protracted gestation, that 
there is no absolute certainty of the moment at which conception 
takes place, as the stopping of the menses is not a guide ; or, at what 
period the woman may quicken, as that differs in different women, 
and at different times in the same woman ; consequently, there may 
be much error in their calculations ; yet, with no better data, Mahon 
insists, that " if the doctrine be true, that the children of old people 
are longer in coming to maturity, it would have been confirmed by 
experience." 

359. We would ask, how could this have been confirmed by ex- 
perience, if they would not rely upon the only data they could pos- 
sess ? For the same objections must attach to the means, and mode 
of calculation, in both instances; and if they be rejected in one case, 
they must in the other. 

years. They were married nearly four years without having issue. On the 7th of 
October, 17G2, lie was seized with fever, and violent oppression, which remained until 
his deoth. The last symptoms were so severe, that he was forced to sit in his bed, nor 
could he move without assistance. In addition to these, he was seized with dry gan- 
grene of the leg on the 21st, and with this accumulation of disease he gradually sunk 
and died on the 17th of November, aged seventy. six years. Renee had not slept in the 
chamber during his illness; but about three and a half months after his death she sug- 
gested that she was pregnant, and on the 3d of October, 1763, (within four days of a 
year since* the illness of her husband, and ten months and seventeen days after his 
ihe was delivered of a healthy, well-formed, and fill-sized child. The opinion of 
Louis was asked in this case, and he declared the offspring to be illegitimate." 

The above cases, notwithstanding Dr. Beck's scepticism, appear, (with the excep- 
tion of the last,) tu be well attested instances of prolonged g< station. The first case, from 
Bartholin, is particularly in poim, and well worthy oi consideration. To us, it appears 
a little sturdy on the part of Dr. Beck, not to have given a little more credit to the 
cases and authorities he has so liberally quoted. Had he done fo, it might have saved 
the expression of contempt for those who differ in opinion with him in this point, con- 
tained in tlic following advice to them. " I recommend to those who intend embracing 
the doctrines of protracted gestation, an examination of the following case. If they 
can satisfy their minds respecting it, all difficulties on this subject will vanish. The 
husband had been absent four years, at the end of which period, the wife brought forth 
a child. She pleaded that her conception had taken place through the force of imagina- 
tion alone — ' ut mulicr per fortem imaginationcm putaverit, se in insomniis rein habu- 
isse cum marito, atquc sic concepisse.' The parliament of Grenoble, to whom this 
case was referred, declared the offspring legitimate." — Metzger, p. 416. Schlegel, 
Vol. 2. p. I 

Dr. Beck confined his ridicule to the above, and a few other cases, almost as 
prepost rous and incredible, we should have been better pleased with his mode of treat- 
ing this subject ; for it is not into the truth of such stories that we mean to inquire ; 
nor from such vague testimony that we mean to draw our inferences. 



120 OF THE TERM OF UTERO-GESTATION. 

360. "Grief also, and the depressing passions, are much relied 
upon, as possessing a delaying power ; but certainly these are more 
apt to produce abortion, than protracted gestation." We do not 
know the fact, but we are persuaded from these last observations, 
that Mahon was not an accoucheur of experience ; for had he been 
extensively engaged in the practice of midwifery, he could not have 
failed to observe that a grief and the depressing passions," have "a 
delaying power ;" and that they do not dispose to abortion. Passions 
andjemotions of the mind have this tendency when in excess ; but 
" grief and the depressing passions," have not. On the contrary, it 
is in strict conformity with our experience in a considerable number of 
cases, that they have a delaying influence. 

361. " That the menses in married women may be suppressed not 
only from disease, but from affections of the mind, or accidental 
causes, which do not immediately impair the health, while the in- 
crease of volume in the abdomen may originate from this, or from 
numerous other causes. 

362. We have admitted, that the disappearance of the menses, is 
by no means to be exclusively relied upon ; but when the stoppage 
shall correspond with the period of quickening, a pretty near estimate 
may be formed. And it may be proper to observe, that when the 
menstrual discharge fail in the married woman hitherto healthy and 
regular, the presumption, that it is arrested by pregnancy, is strength- 
ened; especially, as when this happens from either disease, or, " af- 
fections of the mind," it is rare for impregnation to take place during 
the continuance of the suppression. 

363. "If this doctrine be allowed, how shall we distinguish a 
delayed child from one that is born at nine months ; and by what 
means are we to detect fraud in such cases ? 

364. With the difficulties which may be presented to the medical 
jurist by these cases, we have nothing to do. In our opinion, the 
fact of prolonged gestation is established beyond controversy; and 
this being so, it rests with those who have the settlement of the 
question, to find out the respective marks, which may distinguish 
each case. 

365. " Certainly, as far as we can judge from the narratives given, 
the infants born after protracted gestation, were not distinguished 
for size, or other appearances of maturity." 

366. This declaration is at least at variance with the opinions of 
Mauriceau, Lamotte, and Orfila ; as well as with that of Dr. Hopkins, 
who gave evidence in the Gardner Peerage cause. See " Minutes 
of the Medical Evidence," &c, by Dr. Lyall, p. 71. 

367. And were " the infants born after protracted gestation not 
distinguished by size or other appearances," it would not militate in 
the slightest degree against the doctrine ; as we are of opinion, that 
the tardy development of the foetus may be one of the causes of de- 
layed gestation. 

368. We were at one period opposed to the doctrine of protracted 



OF THE TERM OF UTERO-GESTATION. 121 

gestation ; for we had adopted that of the immutable nature of this 
operation, as regarded duration. But the case already referred to, 
(321,) convinced us that the period of nine calendar months could 
certainly be exceeded by at least thirteen days. This led us to a 
careful investigation of the subject, and which has resulted in the 
entire belief, that the commonly fixed period may be extended from 
thirteen days to six weeks, under the influence of certain causes or 
peculiarities of constitution. 

369. Nor do we feel disposed to abandon this opinion, by all the 
ridicule which has been heaped upon it ; nor from the apprehension 
that our cherishing it will have the slightest tendency to subvert 
good morals, or to offer inducements to the wicked and designing, to 
practice upon either the credulity of husbands, or the good faith of 
friends. The checks to impositions of this kind are both certain and 
numerous : and they would not fail to be employed against the attempt. 

370. We have upon record several remarkable histories of modern 
date ; in addition to those already noticed, which seem to establish 
beyond doubt, that human utero-gestation may very much exceed 
nine calendar months. And as they are not within general reach, it 
may be acceptable to the reader to have them presented. 

371. Case I. A woman, aged twenty-seven years, though much 
emaciated and very weak, in the month of October, 1820, had all 
the symptoms of pregnancy. About the middle of the fifth month 
she began to feel the motions of the child, and at the end of the ninth 
felt the precursory pains of labour. The surgeon, who was called, 
found the pains weak, and the os uteri not much dilated, though 
sufficiently so to allow him to feel that the vertex presented. In 
consequence of the extreme weakness of the patient, she was treated 
with permanent and diffusible stimuli, and with so much advantage, 
that at the end of six weeks she had regained the appearance of 
health, and had returned to her ordinary occupations. 

372. A few days after the coming on of the pains, the motions of 
the child became weaker, and eventually ceased. The size of the 
belly diminished, and the child appeared turned to the left side. 
The menses appeared in the tenth month, and returned regularly 
afterwards. In December, 1821, Mr. Penker was called into con- 
sultation, and advised forcible delivery, which was not consented to. 
In October, 1822, he found the os uteri above the symphysis pubis, 
inclined obliquely half an inch to the right side, with the fundus to 
the left. 

373. The posterior surface of the uterus had descended so low in 
the pelvis, as not to be more than an inch and a half from the 
orifice of the vagina ; and was not thicker than a double sheet of 
paper. The back and feet of the child could be felt through the ab- 
domen. Such was the state of the patient in March, 1823 ; up to 
which time, she had refused to submit to any operation. The relator 
of this case promised the sequel at some future time. 

374. The translator of the above history has favoured us with the 



122 OF THE TERM OF UTERO- GESTATION. 

following remarks upon it. "Although this case is described as a 
uterine pregnancy, there are some circumstances connected with it, 
sufficient to suggest a doubt on that point. If not extra-uterine, there 
is every probability, that it is an instance of retroversion, continuing 
through the whole period of pregnancy, an occurrence often mistaken 
for the real extra-uterine case, as has been fully proved by Dr. Mer- 
riman in his ingenious essay on that subject. 

375. It would have afforded us much pleasure and perhaps equal 
instructions, had the "translator" favoured us with the points of re- 
semblance between this case and an extra-uterine conception ; or, 
between it and a " case of retroversion continuing through the 
whole period of pregnancy." For as regards ourselves, we do not 
see the slightest resemblance to either of his supposed cases. 

376. It could not have been an extra-uterine case, because we 
are distinctly told, that " the os uteri was not much dilated, though 
sufficiently so as to permit him, (the attendant,) to ascertain that the 
vertex presented." That settles this part of the question. 

377. As regards its resemblance to a case of retroversion at full 
time, it is equally out of the question. 1st. Because up to the ninth 
month, there is no symptom recorded, that would lead to the sus- 
picion that this acciden. had taken place. 2d. Because, up to this 
period, the os uteri is not said to have been out of its natural or or- 
dinary situation ; on the contrary, it is distinctly stated that the 
attendant was able to pass a finger into, and to determine it was a 
vertex presentation. 3d. Because there is no mention made of a 
tumour occupying the posterior and inferior portion of the pelvis ; nor 
a single symptom to lead to the suspicion of such a case even after 
the ninth month 

378. We are told that the patient had been " weak and much 
emaciated ;" but was relieved of both by the use of stimulants ; is it 
probable that stimulants would have improved the condition of a 
patient who was labouring under a permanent retroversion of the 
uterus? The only circumstance in the history of this case which 
could lead to the supposition of its being one of retroverted uterus, 
was, that Mr. Penker found the os uteri above the symphysis pubis ; 
but this was twelve months after labour-pains had appeared and 
ceased, and nearly as long after the quiescence, if not the death of 
the child. 

379. Again, Mr. Penker speaks of the posterior surface of the 
uterus being no thicker than a double sheet of paper. If it were 
a retroversion of the uterus, how could Mr. Penker have felt it? and 
especially as this part is represented to be so much stretched by the 
head of the child. For this part must be behind the vagina, in a 
case of retroversion. Moreover, he expressly states, that the head 
of the child had descended very low in the pelvis, and but an inch 
and a half from the os externum. 

380. Were this even admitted to be a case of retroversion, it could 
only have become so after the death of the child, and after the belly 



OF THE TERM OF UTERO-GESTATION. 123 

had diminished in size. But to put this question to rest at once, we 
are told that " the back and feet of the child could be felt through 
the abdomen." Now, it is impossible that these circumstances could 
obtain, and be a case of retroversion at the same time. Indeed, we 
are inclined to believe that Dr. Merriman himself, in a subsequent 
edition of his work, will not select this case, to support his hypo- 
thesis. See Essays on various Subjects connected with Midwifery, 
by the author ; in which he has ventured to offer strictures upon Dr. 
Merriman's opinion on this point, p. 291. 

381. Since the above was written we have met with the history 
of a case, so analogous to the one just related, and which dissection 
proved to be a uterine pregnancy, as to leave no doubts upon our 
minds that the case of Mr. Penker was one of a similar kind. This 
case is one of great interest ; inasmuch, as it shows the very extra- 
ordinary indifference of the uterus at times to foreign bodies within 
its cavity, (for we must look upon the child and its appendages as 
such, after they have parted with their vitality,) after it has made un- 
successful attempts for their removal at the last period of utero-ges- 
tation. We will relate the case as concisely as will be consistent 
with its importance. 

382. Mrs. A. H., aged twenty-nine years, became pregnant about 
the first of April, 1822. She was much afflicted at various periods 
of gestation, with spasms of the stomach and vomiting. She quick- 
ened about the fourth month. After this period, her spasms, &c. 
were less severe ; but new evils supervened ; such as pains in the 
hips, loins, back, &c. About two weeks before the expected period 
of labour, she was attacked with the usual symptoms of this process. 
These continued for ten hours, and then subsided ; from this time 
no motion of the child was felt. 

383. 1822 " March 1st. — She was attacked with phlegmasia alba 
dolens, in one limb. The disease, having left this, soon seized upon 
the other. During the first and second week of this attack, she had 
a discharge from the vagina, resembling the catamenia. At times 
this was fetid ; the os uteri was closed ; no portion of the child could 
be felt. The abdomen very tense. 

384. u About the 20th of March, she began to recover ; and soon 
was able to walk some distance without fatigue. From the 1st 
of April, convalescence was rapid. The tumefaction of the ab- 
domen began to subside ; she appeared to be as large as at the 
seventh month. 

385. " June 10. — Catamenia ; health good ; farther subsidence of 
the abdomen. November, 1823. — Nothing remarkable occurred up to 
this time. Abdomen nearly to its natural size. A small tumour of the 
shape and size of a child's head remains. Two weeks after the sup- 
posed death of the child, milk was secreted, and continued in small 
quantities until October. 

386. "April 10th, 1824. — She was attacked with pain, vomiting, 



124 OF THE TERM IJTERO- GESTATION. 

cough, &c, and continued in this way until the 24th of May, when 
she died. 

387. Dissection. — "Upon opening the abdomen, the uterus was 
discovered to be very much thickened, and presented the appearance 
of having been inflamed, and to have suppurated. 'It adhered closely 
to all the surrounding parts and organs. Anteriorly, it was united 
intimately with the peritoneum, and in this way with the abdominal 
parietes. An incision was made through the anterior face of the 
uterus and a full-grown foetus was discovered." New England 
Journal, No. III. Vol. XIV. 

388. It would be difficult, perhaps, to find two cases so strongly 
resembling each other in most of their leading and material points, 
as these just related ; and the latter most satisfactorily proves, that a 
uterine pregnancy may continue very much beyond the ordinary 
period assigned for gestation. In this case, as well as the former, 
the material points were substantially the same. 

389. First. At the usual period for gestation to terminate, labour 
pains commenced, and continued unavailingly for some time. 

390. Second. In neither case were the pains renewed, after the 
first attempt was made by the uterus to relieve itself; and the motion 
of the children ceased about the same period. 

391. Third. There was a regular return of the catamenia in both 
instances, some time after the cessation of pain, and in both, an 
amendment of health, after this period, for a certain duration. 

392. Fourth. In both instances, the abdomen gradually diminished 
in size ; but in one, a tumour resembling in feeling and in size a 
child's head, was perceived through the abdominal parietes ; in the 
other the back and feet of the child were to be felt. 

393. Now, in the latter case, there was full as much reason for 
considering it an instance of extra-uterine pregnancy, or a retrover- 
sion continuing until full time, as the other ; and would have been so 
looked upon, perhaps by the gentleman who translated the former 
case, had not dissection settled the point. 

394. How the first cause may eventuate we can only conjecture ; 
it may end with safety to the woman, should the uterus so far regain 
its natural susceptibilities and powers, as to throw its contents off per 
vias naturales ; or inflammation may ensue, and the uterus discharge 
itself by ulceration ; or, in case the system is not able to institute this 
process, she may die, like the woman in case second, of inflammation, 
and general irritation of the system. 

395. In our opinion, these cases offer irrefragable evidence, that 
the uterus may remain quiescent, for a long period after the termina- 
tion of the ninth month ; and though we acknowledge them both to 
be extreme cases, they nevertheless prove the fact contended for. 



CAUSE OF LABOUR. 125 



CHAPTER XI. 

CAUSE OF LABOUR. 

396. Avicenna, centuries ago, declared that labour was a law of 
God, and that it came on at the appointed time. I would ask, has 
any hypothesis since that period, enlightened us more upon this sub- 
ject than the humble confession of this honest old man? Ingenuity 
has attempted much upon this subject ; but each suggestion has been 
displaced to give room to another, which like its predecessor was to 
be crowded out by some newer speculation. Thus, Harvy and others 
supposed that the stirrings of the foetus itself contributed to the pro- 
duction of labour, and "that it had much agency in its own deliver- 
ance ; but it had often been proved, that labour was sometimes pre- 
maturely induced by the death of the fcetus ; and that in many in- 
stances, delivery was more rapid with a dead than with a living 
child. 

397. Others have declared, that the desire of the foetus to have 
food, and to breathe, were the causes of the first contractions of the 
uterus ; but the force of both these conjectures is completely destroyed 
by the argument just adduced. The liquor amnii, it has been said 
becomes acrid towards the latter period of gestation, and by the stim- 
ulus forces the womb to labour. But no such change in the quality 
of this fluid has ever been shown ; and as it cannot come in contact 
with the immediate surface of the uterus, in consequence of the 
interposition of the membranes, no faith can be placed upon this con- 
jecture, were it even proved that the waters of the amnion had be- 
come acrid. 

398. The explanation of Baudelocque is very much more plausible, 
and better supported. He makes it consist in a kind of mechanical 
necessity; he is of opinion that the body and fundus, by their per- 
severing, alternate contractions, especially after the sixth month, 
oblige the neck of theuterus to unfold; and the same agency, to- 
gether with the weight of the child, constrain the os uteri to open, 
and labour to take place. This hypothesis has some important facts 
to sustain it; for the action spoken of really exists; and after it has 
commenced, the neck of the uterus gradually expands; and it is 
eventually obliterated, and labour ensues: but a number of facts, in 
which this change did not, or could not take place, destroy much 
of the force of this ingenious suggestion : thus labour comes on 
spontaneously in some females at the seventh, and others at the 
eighth month of pregnancy, while others abort at certain periods, 
without any evident cause. 

399. The latest explanation we have seen is that of Mr. Power, 
12 



126 



CAUSE OF LABOUR. 



"which may be looked upon as a slight modification of that of Baude- 
locque's ; both being strictly mechanical ; and the agent, the wedge. 
Mr power says, (Treatise on midwifery, &c, p. 27.) *' When the 
state of dilatation, has proceeded so far that the os uteri is opened 
to the size of a shilling or more, a portion of the adjoining mem- 
branes begins to be protruded through it; the effect of the paroxysm 
now impels upon them a quantity of the liquor amnii, by which they 
become distended into a roundish tense bag, resembling a portion 
of a blown bladder, filling up the orifice, and at the same time, 
pressing forcibly upon it, on the principle of a wedge, so as to pro- 
mote the dilatation ; this which is called the gathering of the waters, 
is of much utility in the process, as instead of the hard head of the 
child, it offers a soft, regular, and easy medium, by which the dila- 
tation is effected. In proportion as it advances, the size of the 
membranous bag increases, until at length the os uteri is fully 
opened." This explanation does not provide for those cases (which 
are not unfrequent) where the membranes rupture, either accidently, 
or by some cause capable of that effect, a fortnight or even more 
before the uterus betrays any disposition to take on the parturient 
effort. — Yet the orifice dilates in such cases with as much certainty 
as success. Now this could not happen if Mr. P's. explanation be 
the correct one. 

400. We will now examine this opinion a little in detail : First, 
it is stated, that, " vihen the Hate of dilatation has proceeded so fa?' 
that the os uteri is opened to the size of a shilling or more, a portion 
of the adjoining membranes begins to be protruded through it," fyc. ; 
which membranes are eventually, by being impelled by the con- 
tractions of the uterus, to effect the complete dilatation. Secondly, 
that these distended membranes "resembling a portion of a blown 
bladder, fill the orifice, and at the same time press forcibly upon it 
* on the principle of the wedge,' so as to promote the dilatation." 
Thirdly, it is declared that the os uteri is filled up by the distended 
membranes. 

401. It is evident at first sight, that the scheme proposed by Mr. 
Power, for the dilatation of the os uteri, requires the agency of two 
distinct and widely differing powers for its completion, (though he 
acknowledges but one ;) namely, one which shall open the orifice 
" to the size of a shilling or more ;" and a second, (which is entirely 
mechanical,) to complete the expansion; the latter consists of the 
distended membranes, which are to enter the os uteri on the prin- 
ciple of the wedge, and so promote the dilatation. 

402. Now, from all that Mr. Power says after this exposition, of 
the manner in which the os uteri becomes expanded, it is evident 
that he intended, a mechanical power should be considered as the 
sole and efficient cause of this phenomenon. This being the case, 
we would inquire, by what influence or power was the os uteri first 
dilated to "the size of a shilling or moreV It could not have been 
by the distended membranes ; for Mr. P. declares that this does not 
take place until after this degree of opening has been effected. 



CAUSE OF LABOUR. 127 

403. Is it not then probable that the uterus possesses some or- 
ganic power by which it effects the opening of the os uteri, which 
is totally independent of the mechanical influence of the distended 
membranes, since a certain degree of dilatation takes place with- 
out their agency? And if this be true in part, as is admitted by 
Mr. P., may it not be capable of effecting the entire expansion of 
this part ? \Ve certainly think so ; and in our chapter "On Labour," 
in the section treating of the manner in which the os uteri becomes 
opened, we have given our views upon this subject, to which we 
beg to refer the reader. 

404. Indeed, Mr. P. himself, immediately after declaring the 
necessity and efficiency of the distended membranes to produce the 
dilatation of the os uteri, goes on to say, " In proportion as it ad- 
vances, (the dilatation of the os uteri,) the size of the membranous 
bag increases, until at length the os uteri is fully opened." By this 
admission, the order of cause and effect are reversed ; above, we 
are told that the distended membranes enter the os uteri after it is 
opened to the size of a shilling or more, and on the principle of a 
wedge, effect its enlargement ; immediately below we are informed, 
that the size of the membranous bag increases in proportion to the 
dilatation of the os uteri. 

405. In the first instance, the extent of dilatation of the os uteri is 
in proportion to the size of " the roundish tense bag ;" in the next, 
the size of the membranous bag is commensurate with the expansion 
of the mouth of the uterus : now, the membranous bag cannot be 
both active and passive at the same instant. 

406. Besides, Mr. P. makes the uterus perform a work of supere- 
rogation in effecting the opening of its mouth. For agreeably to him, 
as we have shown above, the active agent in the production of this 
effect is the mechanical influence of the distended membranes against 
the orifice of the womb in the time of pain ; yet he informs us with 
a commendable candour, though not intended as a concession, that 
u as the paroxysm comes on, the orifice begins to acquire a tense and 
constricted feel, its internal rim becomes more perfectly circular, fixed 
and incapable of being moved laterally by the action of the finger." It 
is evident, therefore, if Mr. P's. explanation be the true one, that 
nature is at variance with hereself ; a circumstance that very few will 
admit, when she is performing the ordinary functions of the system. 

407. Agreeably to this scheme, the fundus and body of the uterus 
contract with the effect of pressing the presenting part against the ori- 
ficium uteri, that it may be expanded sufficiently to permit the child 
to pass ; but this intention is effectually frustrated by the perverseness 
of the os uteri. For instead of yielding kindly to the impulse of the 
fundus and body, as we suppose it should do under such circumstances, 
it opposes their efforts, by becoming tense, and constricted, and thus, 
at once defeating the very object of the " parturient paroxysm." Now, 
we admit that this really does take place; that it is continued for some 
time ; and that it is attended by these very circumstances. But after 



]28 CAUSE OF LABOUR. 

a longer or shorter time, the orifice of the uterus is found dilated, and 
this without the mechanical aid of the distended membranes; for 
under the best condition of this part it is found fully expanded with- 
out the membranous bag (however tense this may be) engaging in 
its circle ; consequently, without its being directly, and physically 
acting within this circle, like a wedge. 

408. It must be evident, if the distended membranes are to act 
upon the principle of the wedge, they must be, for this purpose, in 
complete possession of the uterine circle ; and if placed thus they must, 
(caeteris paribus,) stretch it quaqua versum, and thus tend to thicken 
the edges, by making them encroach upon the portions of the neck 
of the uterus, not dilated ; but this never, or but very rarely, takes 
place.* Now, it is familiarly known to almost every obstetric prac- 
titioner, that when the os uteri is about to yield in its kindest manner, 
that nearly the whole of that portion, which in the unimpregnated 
state constitutes the neck, becomes by the continuance of labour, 
thinner and thinner ; and especially at that part which constitutes its 
mouth, until at last it becomes so attenuated, and, as it were, so para- 
lyzed, that it discontinues its opposition, and fully dilates itself; and 
all this happens without the agency of the membranes ; or, (if they be 
ruptured,) the presenting part engaging in the circle of its retiring 
edges ; unless it be after the os uteri has become fully dilated. f 

409. Again, Mr. P. tells us, that the " parturient paroxysm, obliges 
the presenting part to approach nearer to the external orifice, with a 
degree of force which the finger is incapable of resisting, and by which 
the orifice is often sensibly enlarged. A few lines above, and in the 
same paragraph, he declares, as we have just stated, that this part, in 
consequence of the paroxysm, " acquires a tense and constricted feel, 
its rim becomes more perfectly circular, fixed, and incapable of being 
moved laterally by the action of the finger." 

410. Notwithstanding these declarations, Mr. P. will have us 
believe, that the (generally) frail membranes, will overcome a resist- 
ance, which the united efforts of the body and fundus, and an intro- 
duced finger is incapable of; for the membranes effect, agreeably to 
him, the dilatation of the os uteri by their presence within its circle. 
Now, it must be evident that they cannot do this even according to 
his own showing, without exerting a force upon the uterine mouth, 
superior to the resistance with which this part maintains its contrac- 
tion ; and this is acknowledged by him to be more than equal to any 

. * See Chapter " On Labour." 

t That is, agreeably to our view of the subject, the circular fibres of the neck and 
mouth of the uterus, relax; themselves, by a law of the uterus ; and thus give to the lon- 
gitudinal fibres the control : for by the contraction of the latter, the uterus becomes 
shorter, and consequently will widen itself at its opening, by drawing the circular fibres 
upwards. When this happens, the mouth of the uterus is drawn, or has a tendency to 
be drawn upwards, and the presenting part escapes from it — hence, after the complete 
expansion of the os uteri, its margin is often not to be found ; but when it is not re- 
tracted, it advances before the head of the child; and though every way disposed to 
dilute fully, or yield to the passing head, it often remains in that situation, so as to be- 
come a cause of tedious or difficult labour, See chapter on Tedious Labour., 



CAUSE OF LABOUR. 129 

degree of force that the finger could exert in order to move it later- 
ally.* Is it for a moment to be believed, that these membranes can 
exert such a degree of force ? But, to put this subject at rest, we 
have attempted to show, in the section above referred to, that the 
most entire dilatation of the os uteri takes place without the inter- 
vention of the distended membranes, or even of the presenting 
part. And Mr. P. must have met with similar cases in his own 
practice. 

411. Having premised the above explanation and the effect of the 
" expulsive or parturient action," Mr. P. proceeds to the considera- 
tion of the nature and cause of the " parturient action." Under this 
head, Mr. P. offers a new and certainly, an ingenious hypothesis : 
which it becomes our duty to examine, lest it be too easily admitted 
as true. 

412. Mr. P. commences his subject, by an unnecessary endeavour 
to prove the muscularity of the uterus, and that its action is similar 
to that of other muscles. He next informs us, that this organ is libe- 
rally supplied with nerves from several sources ; and that the neck 
of the uterus is, in an especial manner, furnished with them ; and 
hence the great sensibility, upon which he grounds his hypothesis. 

413. He declares the uterus to be disposed to expel its contents 
during the whole term of utero-gestation, whenever a sufficient ex- 
citing cause is applied ; and that this disposition is inherent, and not 
adventitiously acquired during pregnancy. He then asks, " What is 
then the nature of that exciting cause, which in parturition determines 
the uterine muscles to these efforts at so exact a period?" p. 33. He 
contends that " the exciting cause, although acting upon the suscepti- 
bility of the uterus to receive its impressions, does not appear innate 
in the uterus itself, but probably consists of some principle, externally 
or mechanically applied to it," p. 34. 

414. He attempts to support these opinions, by ingeniously employ- 
ing analogies furnished by the actions of the rectum and bladder ; 
and being thus strengthened, as he believes, he proceeds to a more 
detailed exposition of the modus operandi of the causes which act 
upon these peculiar susceptibilities of the uterus. 

415. " It has been observed, that a regular series of change takes 
place in the cervix of the uterus during the latter months, which only 
becomes completed at the end of gestation, and immediately before 
the commencement of parturition. This change has been stated to 
consist of a gradual opening, or expansion of the cervix ; during the 
earlier parts of gestation, the uterine contents, are at a distance 
from its orifice ; but as the expansion proceeds, they gradually ap- 

* We are not certain that we have arrived at>the exact meaning of the word " later- 
ally," as employed by Mr. P. We presume, however, that he intends to convey the 
idea, that the os uteri cannot be stretched by an introduced finder in that direction, 
during the "parturient paroxysm," or, in other words, that at this time it maintains 
its "constriction " wi'h an obstinacy, that is not to be subdued by any safe degree of 
force that could be applied by the finger. 

12* 



130 CAUSE OF LABOUR. 

proximate : when it is completed, they are contiguous, and the pro- 
cess of expulsion soon succeeds. A strong analogy may be here ob- 
served, with the case of fecal evacuation, in which a gradual pro- 
gress takes place of the fecal contents towards the sphincter, and in 
which also the ready disposition to contract is proportionate to that 
progress; and is most perfect when they are contiguous." In order 
to understand this analogy, we must relate Mr. P's. notions of this 
act. He considers the rectum as a mere receptacle for the feces, with 
which it becomes gradually filled ; " the first portions of which enter 
the rectum, and occupy the farthest extremity," (that is, the upper 
portion of this gut,) " but as each successive portion is received, the 
former one is protruded forward by the impulse from behind, assisted 
by the contractile power of the part, until it eventually arrives at the 
anterior extremity or sphincter : in proportion, as the accumulation 
takes place at this point, a stimulating effect is produced upon it, the 
irritation of which is at length followed by the action of the muscular 
coat of the rectum, which presses forcibly upon the feces, and expels 
them." p. 34. 

416. Between the illustration just given, and the exciting cause of 
labour as stated by Mr. P., we do not perceive the slightest analogy; 
nor can any exist if Mr. P's. explanation be right, and for the follow- 
ing reasons : First, Because the relaxation of the sphincter ani which 
precedes the expulsion of the feces, is an act of the will ; for from 
the constant tendency of the rectum to become distended, it requires 
that the excrementitious part of the food should be occasionally car- 
ried off; and this is done whenever the rectum is filled ; for the irrita- 
tion occasioned by its distention advertises the individual of the ne- 
cessity of its being emptied ; he wills that this should take place ; in 
obedience to which the sphincter ani is relaxed ; the effect of expul- 
sion follows ; and the rectum is relieved of its contents.* 

417. Secondly, Because Mr. P., makes the opening of the os uteri 
to depend upon mechanical force, whereas the sphincter ani requires 
no such force, to eall the auxiliary powers concerned in the discharge 
of the feces into action. The " irritation" which calls the attention 
of the will, (if we may so term it,) to this act, does not necessarily 
reside in the rectum ; or rather on the verge of the sphincter ani ; for it 
is often seated in the stomach, more frequently in the bowels, and 
sometimes only in the imagination. 

418. Thirdly, Because we do not find this " irritation" always 
produced by the presence of a large quantity, of even indurated, (and 

* It is true that the relaxation of the sphincter ani is not always in obedience to 
the will ; and may, whea this happens, be considered as militating against this objec- 
tion ; but this it surely does not do, under the point of view this subject is examined 
— for when involuntary discharges take place, 4 the parts both directly and indirectly 
concerned in the operation, are labouring under disease; consequently, must not be 
looked upon as illustrative of a healthty or normal action. The brain may be so dis- " 
ordered, that the will cannot act ; or the sphincter may be so morbidly irritable as not 
to be under' its control ; or the actions associated with the irritations of the rectum 
may be so susceptible of impressions as to force the sphincter to obedience. 



CAUSE OF LABOUR. 131 

as it would seem more highly stimulating from their mechanical pro- 
perties,) feces ; as in constipation. 

419. Fourthly, Because some of the most violent, tormenting, and 
frequent discharges from the rectum, are not caused by the presence 
of feces in this gut ; as in tenesmus, or dysentery; nor is distention 
necessary always to the relaxation of the sphincter ani ; as we see in 
diarrhoea. 

420. Fifthly, Because Mr. P. makes the opening of the os uteri to 
consist in a mechanical stretching; but the opening of the sphincter 
ani is a functional act ; namely, the relaxation of a muscular band, 
and subject to the control of the will. 

421. Sixthly, Because Mr. P. confesses that there is a conscious- 
ness of the presence of some irritating substance applied to the sphinc- 
ter ; for, he says, " that during the earlier periods of accumulation, no 
disposition to expulsion is perceived ; and in the latter period, when 
the sensation of want of expulsion comes on, it is always referred to 
the sphincter." Now, it is known to every body, that at neither the 
commencement of labour, nor during any period of its progress, is 
any sensation experienced at the sphincter of the uterus; nor can any 
woman will its relaxation or contraction. 

422. The same arguments may be employed against his other ana- 
logy : namely, the filling of the bladder, and the extrusion of the urine, 
as it is founded upon the same principle, and derives support from 
similar phenomena. , 

423. Having first given Mr. P's. views of the manner in which the 
os uteri becomes expanded, we will proceed to examine the prin- 
ciples on which he predicates " the nature and cause of parturient 
action." 

424. Mr. P., after briefly relating the order of changes in the de- 
velopment of the uterus, up to the commencement of parturition, says, 
" During the earlier months of pregnancy, the uterine contents are at 
a distance from its orifice : as the expansion proceeds, they gradually 
approximate ; when it is completed they are contiguous, and the pro- 
cess of expulsion soon succeeds." A strong analog} 7 may be here 
observed with the case of fecal evacuation just noticed, in which a 
gradual progress takes place of the fecal contents towards the sphinc- 
ter, and in which also the ready disposition to contract is proportionate 
to that progress ; as is most perfect when they are contiguous ; but the 
analogy does not rest here, as it may be shown that the nervous struc- 
ture connected with their respective organs, are not only similar, but 
derived from the same origin, both being supplied with nerves from 
the hypogastric trunk, of which one division is expended upon the 
rectum and its sphincter, the other upon the uterus and vagina. Is 
it not reasonable to suppose this similarity of structure to be attended 
with similarity of action, particularly when we do know, that their 
functions are correspondent, viz. to exclude the contents of their re- 
spective organs ? 

425. " We have hence strong analogy to prove that the contractions 



132 CAUSE OF LABOUR. 

of the uterus are produced, in consequence of a certain impression 
excited by its contents upon its orifice. We shall inquire how far 
circumstances, connected with the structure and actions of the uterus, 
confirm the position. 

426. " It has been admitted that different parts of the uterus are 
possessed of different states of sensibility, and that its orifice is most 
highly charged : upon whatever ground the admission has been founded, 
it is confirmed and illustrated by anatomical observation. We have 
seen it supplied with nerves from the renal plexus, the spermatics, 
and the hypogastric nerves ; the two former, which are chiefly derived 
from the sympathetic plexus, supply the upper parts of the uterus, ovaria, 
&c, and may be considered as the chief media of their communica- 
tions with the general system, or of their sympathetic actions ; the 
latter, though not devoid of connexion with the sympathetic nerves, 
is principally formed from the spinal nerves, which are more peculiarly 
nerves of motion ; it may be considered the chief nerve of the uterus 
and vagina, upon every part of which the largest part of it is expended, 
the lesser one, as before noticed, supplying the rectum ; it, however, 
passes more directly and largely to the os tineas and adjoining 
parts. 

427. "It may hence be inferred, that the orifice of the uterus pos- 
sesses a high state of nervous power, and consequently a peculiar 
function. It has also been observed that this part becomes little con- 
nected with utero-gestation until that office is complete, being pre- 
viously removed to a determinate distance from the distending pro- 
cess. Is it not, therefore, reasonable to consider that its peculiar 
function, so far as it is connected with a high state of sensibility, is to 
give warning of the task of utero-gestation being performed, and to 
be the medium of calling into action the powers which are appointed 
to produce the expulsion of the now mature foetus ?" p. 36, &c. 

428. From what has been just said, it appears that Mr. P. insists 
upon the following positions or principles, as essential to the esta- 
blishment of his hypothesis. 

429. First, That the uterus is gradually developed ; but not com- 
pletely, until the last period of utero-gestation : that is, the neck of 
this organ is not effaced until that epoch. 

430. Secondly, That the design of this arrangement is to keep the 
uterine contents at a distance from the os tincse. 

431. Thirdly, That as gestation advances the contents of the uterus 
and the os tineas gradually approximate : when completed they are in 
contact. 

432. Fourthly, That there is a strong resemblance of nervous 
structure between the uterus and rectum. And that this correspond- 
ence in structure is to ensure a similarity of function ; namely, to 
" exclude the contents of their respective organs." 

433. Fifthly, That the contractions of the uterus are produced, in 
consequence of a certain impression excited by its contents upon its 
orifice. 



CAUSE OF LABOUR. 133 

434. Sixthly, That the different parts of the uterus " are possessed 
of different states of sensibility, and that its orifice is most highly 
charged. 

435. Seventhly, That as the orifice of the uterus possesses a high 
state of nervous power, it must necessarily have a peculiar function. 

436. Eighthly, That the os uteri is but little connected with utero- 
gestation, until this is nearly completed, as the contents of the uterus 
are designedly removed from it. 

437. Ninthly, That the os uteri, from its great sensibility, is in- 
tended to give notice, that the term of utero-gestation is completed ; 
and is the medium by which the fundus and body are called into ac- 
tion, that the foetus may be expelled. 

438. Tenthly, That in proportion to the pressure exerted by the 
uterine contents upon the os uteri, will be the efficiency of the " par- 
turient action," as is illustrated by malposition, &c, &c. 

439. Eleventhly, That the cessation of contraction, in cases of rup- 
tured uteri, is owing to the removal of the presenting part from the 
os uteri. 

440. We trust we have faithfully given Mr. P's ideas on the sub- 
ject in question, in the positions now laid down ; we will therefore 
proceed in order to their examination. 

441. To positions first and second, we w T ould observe, that though 
they are strictly true as regards arrangement, yet that this arrange- 
ment is not for the purposes declared by Mr. P.; namely, that the 
uterine contents should be kept at a distance from the highly sensible 
os uteri, that the parturient action need not be provoked. See prop, 
sixth. 

442. Now it is a fact known to every body, that the complete dis- 
tention of the uterus is not essential to this end ; since the uterus oc- 
casionally expels its contents at every period of gestation, from a 
variety of causes, which cannot in possibility act upon the sensitive os 
tinea as a mechanical irritant. The ergot has been known to produce 
abortion, as well as other substances: so have passions and emotions 
of the mind; as well as external mechanical injuries, as blows, falls, 
&c. 

443. In neither of these instances was it essential to the production 
of the parturient effort, that the uterus should have been fully deve- 
loped, or that the os uteri should have been irritated by the presence 
of the fcetus or embryo, (see prop, fifth and tenth ;) yet the uterine 
contents were thrown off by the repeated contraction of the fundus 
and body. 

444. To proposition third, we may remark that it proves nothing, 
unless it can be shown, that the sensibility included in prop, sixth, is 
exclusively resident in the extreme external edge of the os tincae ; for 
if it be admitted that the nervous distribution is extended over the 
whole of the neck of the uterus, (as is confirmed by anatomy,) prema- 
ture labour should always take place so soon as this part is called 
upon to furnish room for the augmenting size of the fcetus. 



134 



CAUSE OF LABOUR. 



445. For immediately after the sixth month, the neck of the uterus 
is found to expand ; and it continues to do so, until it is entirely ef- 
faced. If, then, the " parturient action" depend upon the application 
of the contents of the uterus to this highly sensible part (according to 
Mr. P.) namely, the neck of the uterus, why is not its sensibility so 
roused by this mechanical impression, as to call into action the partu- 
rient effort, and premature delivery take place ? But we find it alto- 
gether otherwise in the ordinary arrangement of nature ; for it is al- 
most constantly found that the neck of the uterus passively suffers 
itself to be developed, to the last period of utero-gestation, without 
manifesting the slightest repugnance to the operation ; it must there- 
fore be evident, that it would be otherwise, were Mr. P's. hypothesis 
well sustained, since here the agent and capacity are constantly pre- 
sented to each other.* 

446. To proposition fourth, it is scarcely necessary to reply, since 
it also proves nothing. The stomach, the oesophagus, the alimentary 
canal, the gall-bladder, the vesicular seminalis and penis in the male, 
the vagina, all have muscular fibres, elastic membranes, blood ves- 
sels, nerves, &c, like the uterus : yet they prove nothing, by their 
structure, in favour of the position of Mr. P. that the contractile pow- 
ers of the body and fundus are called into action, as an original and 
natural function, in consequence, and by necessity of, an irritation 
produced on the mouth of the uterus, by the pressure of the contents 
of this organ, as declared in prop, fifth. 

447. To proposition fifth, we must declare, that it is not sustained 
by any fact within our knowledge, as a natural and essential arrange- 
ment. It would necessarily require that the extreme sensibility of the 
neck of the uterus should be confined to the extreme edge of the os 
tincse ; [see answer to prop, third,] or that that portion of this organ, 
which, in its vacant state, as well as in a state of impregnation until 
Hie sixth month, called its neck, must acquire a new state of sensibility, 
the instant the full term of gestation is completed ; which condition 
has neither been shown nor insisted on by Mr. P. For if the whole 
neck were possessed of an equal degree of sensibility, premature la- 
bour must take place soon after the sixth month, agreeably to the 
scheme of Mr. P. ; since it is acknowledged by all accoucheurs of ex- 
perience, that there is a constant nisus in the body and fundus ; and 
which is favourable to the expansion of the neck, (par. 206.) 

448. This being the case, it must be evident that the neck will be 
more or less irritated, (if it possessed this extreme sensibility ,) by the 
contents of the uterus being forced constantly against it, by the con- 

* Mr. Power says, rather incorrectly, we think, that the "orifice of the uterus is but 
little connected with utero-gestation, until that office, (of utero-gestation,) is complete," 
[prop, eighth :] as we know that it must necessarily be involved in the development of 
the neck, so soon as this part is acted upon by the contractions of the body and fundus, 
as just stated. And if he shall insist, that "the high state of nervous power," is con- 
fined to the margin of the opening of the uterus, he is bound to show some proof of it : 
for so far he certainly has not. A bare assertion to this effect is not sufficient. 



CAUSE OF LABOUR. 



135 



tractions of the body and fundus ; and which we believe invariably 
takes place, at, or very soon after the sixth month. 

449. Besides, we have no evidence of the " high state of sensi- 
bility," spoken of in prop, sixth, by Mr. P. It certainly does not 
exist, agreeably to our experience, either before or during parturition 
as a natural condition of this part ; for unless it be in a state of dis- 
ease, either chronic or immediately produced by rude and improper 
management, we have no evidence of this state. We can with much 
safety say, we have touched the os uteri a thousand times, without 
the woman betraying the slightest inconvenience or pain. 

450. To prop, seventh, we can only say, that, were this " high 
state of nervous power" admitted to exist, it would prove nothing in 
favour of Mr. P's. hypothesis, unless he can prove that the mouth of 
the uterus always obtains it at the moment that utero-gestation is 
finished. For if he cannot do this, and he insist, that it takes place 
during the progress of gestation, it would certainly be mischievous ; 
as it must be acted upon very constantly by a variety of agents ; and 
thus would " give warning of the task of utero-gestation being per- 
fected," and that labour was about to ensue prematurely. 

451. In prop, eighth, Mr. P. seems aware of the difficulty there 
would be to reconcile u this high state of sensibilility" of the orifice 
of the uterus, with the unavoidable production of irritation from the 
presenting part, (did this condition really exist,) as gestation advances, 
and especially after the sixth month. He therefore relies for support 
upon the mechanical arrangement, mentioned in one part of the pro- 
position under consideration, by saying, that the orifice is removed at 
a distance from the distending process." Now, it must be well known 
to so experienced a practitioner as Mr. P. that labour ensues some- 
times before the entire obliteration of the neck takes place ; and that 
it does not necessarily ensue immediately after it is completely effaced : 
neither of which should happen in any thing like the frequency that 
we have occasion to observe it, were Mr. P's. hypothesis well founded. 
Nay, the mouth of the uterus will sometimes be opened to some ex- 
tent for days ; indeed even weeks now and then, without the "partu- 
rient effort" declaring itself.* 

452. The ninth proposition declares, that the great sensibility of 
the os uteri is intended to notify the other portions of this organ, that 
the great business of gestation is finished ; and that they must now 
set in action the parturient powers to remove the product of this ela- 
borate process. It must of necessity follow, that this high state of sen- 
sibility is a sina qua non to parturition ; and that the entire develop- 
ment of this portion of the uterus is a sine qua non to this sensibility ; 

* "A friend, a practitioner and lecturer of some eminence, is positive that he has 
known repeated instances of spurious pain«, in which the cervix uteri has not only 
been entirely ohliterated, but V c orifi< e sufficiently open to admit a couple of fingers, 
and yet labour his been deierr d for nearly a month afterwards. Professor Hamilton 
used to mention cases in which, though the cervix uteri was obliterated, yet real la- 
bour had not commenced." — Note by Dr. Ly a ll to Minutes of the medical Evidence 
given nthe Gardner s Peerage Cause, p. 23. 



136 CAUSE OF LABOUR. 

since Mr. P. affirms that this part is but little connected with utero- 
gestation until this office is complete, [prop, eighth.] The facts de- 
tailed in the observations upon prop, eighth, may be successfully em- 
ployed against these views. 

453. Besides, it is well known that labour comes on as promptly, 
and as certainly, when the foetus dies before its full development, and, 
consequently, before the " task of utero-gestation is perfected. " as 
when it lives to the full period ; yet, in many cases, this does not hap- 
pen until the period of nine months have expired in these instances, 
so far is the neck of the uterus from being completely expanded, that 
a portion of it can be distinctly felt, if it be examined soon after the 
commencement of the pains. Indeed, the whole uterine bulk is often- 
times found diminished. How does the extreme sensibility of the os 
uteri perform its office in these cases ? do they give warning that the 
term of gestation is completed ? 

454. But more powerful objections may be raised against prop, 
tenth, and which w T ill have a direct application to prop, ninth. If 
we understand Mr. P. rightly, and we would feel great reluctance to 
force his meaning, the following circumstances must combine, that 
labour may take place ; first, that an especial degree of sensibility 
must reside in the extreme edge of the os uteri; secondly to make 
this sensibility available, the presenting part must press upon it ; and 
thirdly, if this be of a minor kind, or not regularly applied, the par- 
turient action is less forcibly or speedily excited." p. 39. 

455. The first circumstance we have endeavoured to prove, does 
not exist in the natural condition of the part interested ; and if we 
have been successful in this attempt, it might look like a work of 
supererogation to offer objections to the second and third, as they 
depend, agreeably to Mr. P's. statement, upon the first for their suc- 
cess or influence. 

456. But let us suppose this exalted sensibility to exist; we shall 
soon see that it must be called into action, if the pressure of the con- 
tents of the uterus be capable of doing so, in a vast majority of cases, 
long before the task ; of the utero-gestation is perfected." 

457. The history of human gestation shows, that the contents of 
the uterus is successively forced against the neck of this organ with 
more or less force, immediately after the sixth month is completed ; 
and this, with an urgency that is highly instrumental in its ultimate 
expansion — this alternate state of contraction and relaxation, is cal- 
culated to call into play the functional duty of this part, rather, per- 
haps, as a congenial and appropriate stimulus, than as a mechanical 
agent. But be this as it may, such is the economy of the uterus at 
the period of gestation spoken of, that its contents are regularly urged 
against its inferior portion, and with such force for at least two 
months, as would indisputably interfere with the comfort of the mouth 
of the uterus, did it possess one-half of the sensibility so gratuitously 
.bestowed upon it by Mr. P. 

458. Again, we have the " parturient effort " regularly established, 



CAUSE OF LABOUR. 137 

where there is no foetus within the uterus to be urged against the 
mouth of the uterus (as in extra-uterine conception,) to rouse its sen- 
sibility, that it may give warning, that "the task of utero-gestation 
is perfected." In these cases there can be no warning given by the 
mouth of the uterus, as it is not expanded ; and consequently cannot 
avail itself of pressure, did it even possess the sensibility contended 
for ; since there is not a sufficiency of substance within the uterus, to 
be forced against it; yet the parturient effort is excited. 

459. It is true, Mr. P. is perfectly aware of this objection ; but is 
quite unwilling to admit its full force. He says, that " extra-uterine 
foetation is most commonly attended by pain, but these pains cannot 
arise from real expulsive action of the uterus, as that organ contains 
nothing in fact to expel." We are a little surprised at this declara- 
tion, as it betrays a lack of candour ; for a practitioner so well read 
as Mr. P. cannot be ignorant, that almost every dissection of women 
who have died in consequence of an extra-uterine conception, has 
afforded proof, that the decidua was regularly formed within the 
uterus,* and that, in most of these cases, this substance had been 
expelled by the regular action of the uterus. We need not cite 
authorities in proof of this ; the fact is familiar to every body con- 
versant with obstetrics. 

460. Air. P. farther observes, however, that " such cases do occa- 
sionally proceed through their whole series of phenomena without 
any pain being excited." This may be — and if they do, they only 
form exceptions to the rule. Again, he observes " the pains at other 
times, will commence in the early stage, and continue to be more or 
less excited throughout the whole period of pregnancy." What pro- 
duced the pain in these cases? Most probably, it may have been 
an unusual quantity of the decidua ; for we are informed that it some- 
times abounds. 

461. Mr. P. admits as certain, "that a state of pain which has 
been supposed similar to labour pains, does occur commonly from 
the eighth to the tenth month : it is probable, however," he con- 
tinues, " that it does not partake of the nature of the parturient pa- 
roxysm, but consists of spasmodic actions of the surrounding parts 
unconnected with the uterus. It is also possible that a translation 
may be made from those parts to that organ, upon the principle of 
metastasis ; or the child may gravitate during the latter months upon 
the cervical part of the uterus, which may have undergone some 
similar preparatory change to what it experiences in utero-gestation, 
and thus produce certain actions of the uterus by irritation of the 
cervix," p. 41. 

462. It will be perceived, that there are three distinct positions 
assumed by Mr. P. in the above quotation, with a view to destroy 

* Saxthorp, Langstaff, and Blundcll have each met with a case of extra-uterine 
conception (the latter two) in which there was? no regularly formed decidua; but in all 
there appears to have been an attempt at its formation, as flotculi, albumen and mu. 
cous were found to occupy the cavity of the uterus. 

13 



138 CAUSE OF LABOUR. 

the force the cases of extra-uterine conception offer to his doctrine ; 
all of which we look upon as gratuitous : we shall, therefore, try their 
validity with the arguments and facts which observation has furnished 
us with. 

463. Mr. P. declares it probable, that the pain the woman experi- 
ences between the eighth and tenth months of gestation, w T hen she 
is carrying an extra- uterine conception, "is not of the nature of the 
parturient paroxysm." Why not? has it not all its characters? is it 
not alternate ? is it not situated in the uterine region ? is it not de- 
scribed as a forcing, bearing dow T n pain ? is it not evident that it is 
owing to uterine contraction, since, in most instances, it is accom- 
panied by a slight discharge of blood, and sometimes by the discharge 
of a substance resembling the decidua ? could these phenomena present 
themselves, if this pain "consisted of spasmodic actions of the sur- 
rounding parts, unconnected with the uterus ?" 

464. We anticipate the answer of every candid mind to these 
questions, by believing it would be in the negative. Mr. P. has 
not urged a single reason for the belief, that uterine contraction is 
not the cause of this pain ; why he has not done so, may be easily 
imagined. 

465. Now, it seems to be a matter universally ceded, that there is 
a general and pretty constantly fixed period, at which gestation ceases,* 
and that, as soon as this period arrives, the uterus takes on the action 
of expulsion \ or, in other words, a period arrives very constantly, at 
which the connexion between mother and child must cease — and this 
is, as an average period, made to occupy about two hundred and 
seventy-three to two hundred and eighty days. It is every w T ay pre- 
sumable, that every thing connected with pregnancy in its natural 
order has a definite period of duration ; as every earthly thing has 
beside, that possesses life: consequently, this principle, or condition, 
can be maintained but for a limited time. The decidua then, like 
every thing else, has a limited period of vital energy ; and that, when 
this time arrives, it dies, by a law of nature ; nor can any art with 
which we are acquainted prolong its vital condition, one day beyond 
this limit. 

466. In the human subject this takes place with the decidua, at 
about the end of nine calendar months ; a little sooner, or a little later, 
as its peculiar constitution may be, or as those may be with which it 
is connected. If it die within the uterus, it becomes from that mo- 
ment an extraneous body ; and such is the constitution of this organ, 
that it instantly sets about expelling the body, be it what it may, that 
becomes foreign to it by losing its vitality. Thus it is with the de- 

* Mr. P. admits, " It is an established law of the system, that the connexion of the 
child with its mother should cease at, or very soon after, the ninth month from concep- 
tion ; whenever this takes place, it is probable, that the child becomes an extraneous 
mass, and consequently excites inordinate action of the parts around to produce its 
removal ; whereas it had previously constituted a vital part of the system, and as sucii 
had received both support and forbearance from it," p. 42. 



CAUSE OF LABOUR. 139 

cidua ; it loses its life because it cannot be maintained longer, agreea- 
bly to a law of nature ; it is then expelled, by the repeated efforts of 
the uterus ; and these efforts are accompanied by pain. 

467. In dysmenorrhea, a similar process is instituted to dislodge 
the membrane or eoagulum produced within the uterus. Mr. P. 
might say with equal propriety, in this case, that the pain the woman 
experiences, " does not partake of the parturient effort, because the 
uterus in fact has nothing to expel ;" yet in both instances, it extrudes 
by its action a foreign body. 

463. If these facts, and the reasoning from them be admitted, the 
cause of pain at the end of nine months, (more or less,) in cases of 
extra-uterine conceptions, is accounted for ; and consequently, the ex- 
planation of u the nature and causes of the parturient action," given 
by Mr. P. must fall to the ground ; since, it may, nay, it is constantly 
produced in the cases alluded to, without either the condition of the 
os uteri insisted on by him, or the presence of a child within it, both 
of which he considers as essential to the action in question. 

469. The second position assumed by Mr. P. is, that the uterus 
may be urged to pain, by a translation of action from " the surround- 
ing parts unconnected with this organ." We confess ourselves en- 
tirely ignorant of this change, as we have never witnessed it ; and 
are altogether at a loss to account for pain attacking the surrounding 
parts, under this particular form of conception ; and so uniformly, at 
the same period of gestation, in preference to the uterus itself, which 
every body will admit is more implicated in the progress and con- 
sequences of this mode of gestation, (unless, perhaps, it be the very 
sac itself in which the foetus is concealed,) than any other portion of 
the neighbouring parts. Besides, metastasis is the translation of a 
morbid action: uterine contraction is normal. 

470. The third position assumes an impossibility; namely that 
"the child may gravitate during the latter months, upon the cervical 
part of the uterus, which may have undergone some similar prepara- 
tory change, to what it experiences in utero-gestation, and thus pro- 
duce certain actions of the uterus, by irritation of the cervix." 

471. In cases of extra-uterine conception, the seats of development 
are the ovarium, the tube, and the abdomen ; and to these has lately 
been added a new one ; namely, the substance of the uterus itself. 
Now, if the foetus occupy either of the first three named places, it is 
impossible that it shall " gravitate during the latter months upon the 
cervical part of the uterus ;" unless it be made to reach this part, by 
some process of ulceration, which it is scarcely worth while to an- 
ticipate, as in this case, it would not serve the purpose of Mr. P. 
The whole arrangement or anatomy of the parts forbids the possi- 
bility of a foetus enclosed in either of the viscera just named, from 
being so precipitated in the pelvic cavity, as to come in contact with 
the cervical part of the uterus. 

472. Late pathological researches have discovered that the fretus 
may be included in the proper substance of the uterus. But even 



140 CAUSE OF LABOUR. 

this fact cannot be made subservient to the purposes of Mr. P. He 
declares the possibility of the foetus so to gravitate, as to reach the 
cervical portion of the uterus at the last months of utero-gestation; 
but, in the newly discovered species of extra- uterine conception, the 
period of gestation has hitherto been confined to the first few months, 
and has proved fatal in every instance so far known: consequently, 
cannot be looked upon as a support to Mr. P's. conjecture, (see pars. 
164, 165.) 

473. It may be farther urged against proposition tenth, that the 
irritation caused by the presence of the presenting part,upon the " highly 
sensitive os uteri," should be in proportion to the pressure it may exert 
upon it. Now, this is contradicted by the experience of every day. 
For there are no cases so uniformly slow, as those in which the mem- 
branes have given way early, and in which the presenting part " gravi- 
tates" so decidedly " upon the cervical portion of the uterus." The tonic 
contraction of the uterus almost immediately ensues after the rupture 
of the membranes ; by which the presenting part is made to rest upon, 
and mechanically stretch the most depending part of the uterus, (the 
very situation contended for by Mr. P.:) yet this condition may re- 
main from a few hours to many days, without having this period in- 
vaded by pain. 

474. Proposition eleventh says nothing more, than when the uterus 
is entirely empty, it ceases to contract : this is but as it should be ; or 
the poor female, who has had her uterus once forced to contraction, 
would never have it to cease, did not a state of vacuity prove a gua- 
rantee against them. It is, therefore, every way presumable, that in 
the case of a rupture of the uterus, when the foetus and secundines 
have escaped from it, that this organ would cease to contract, as no 
motive now remained for this function ; to say nothing of the extreme 
state of exhaustion this accident uniformly produces, which of itself is 
capable of arresting uterine contraction. 

475. Mr. P. says " the contractions of the os uteri may be artifici- 
ally excited by an irritation applied to the orifice, affording a proof 
that the cause presumed is adequate to produce the effect attributed 
to it," p.- 39. Admitted; but what does it prove in favour of Mr. 
P's. hypothesis ? Nothing ; especially as Mr. P. will not declare it to 
be a natural state of function. Irritating the fauces will produce vo- 
miting, and a dose of jalap will purge ; but will any body acknowledge 
either to be essential to the emptying of the stomach and bowels under 
the exercise of their natural or normal actions? 

476. Mr. P. with a view of strengthening his conjecture, quotes a 
letter from his father, Dr. Power, of Litchfield. He commences his 
letter by saying, that the " parturient contraction, does not happen in 
consequence of distention of the uterus after nine months' pregnancy, 
but from some stimulus applied to the os uteri may be inferred from 
the following case. 

477. "A woman, forty years of age, the mother of many children, 
considered herself at the full period of utero-gestation, and experi- 



CAUSE OF LABOUR. 141 

enced at that period a slight pain or two, after which she became free 
from any farther effort for nearly three months ; her situation exciting 
alarm, several medical gentlemen saw her, and declared, after exami- 
nation per vaginam, that she was not with child, as they could feel no 
weight upon the os uteri, or variation of it, from what is found in the 
unimpregnated state. I saw her, and in a common examination as 
she lay upon the bed, found matters apparently as had been repre- 
sented ; observing, however, the abdomen very large and pendulous, 
hanging down when in an erect posture almost to the knees. A friend 
of hers, a physician of great eminence, who was present, was requested 
to stand above her on a chair, and to elevate as he stood, the pendu- 
lous belly with the assistance of a napkin ; an examination was made 
under these circumstances per vaginam, and I could feel now dis- 
tinctly the head of the child. A bandage was contrived with straps 
to her stays, by which the child was removed from its situation over 
the pubes ; and in four or five days labour pains came on, and she 
was delivered of an amazing large but still-born child," p. 40. 

478. To this case it will be only necessary to observe, that there is 
not the slightest evidence of the agency of the presenting part, in pro- 
ducing labour. For it is acknowledged that the patient was the mother 
of " many children ;" and, consequently, liable from this cause to the 
anterior obliquity of the uterus. It is by no means probable, that this 
was the first instance of deviation ; especially as it was so extreme as 
to reach nearly to the knees when the woman was standing. If it 
existed in her previous pregnancies, how did labour commence in 
them, if the aid given by Dr. Power was essential to this process, 
since it was not resorted to upon the former occasions ? 

479. Besides, Dr. P. acknowledges that four or five days elapsed before 
labour took place ; if this be so, what evidence is there that the head 
pressing against the os uteri was the cause of it? none whatever. It 
is much more probable, if any thing had an influence upon uterine 
contraction, that it was the change of position and the bandages; as 
it is well known that externa] friction over the body and fundus will 
produce contraction, even when the uterus is in a state of inertia. 
Again, we have seen many cases of anterior obliquity, in neither of 
which was it necessary to have recourse to the means employed by 
Dr. P. to provoke labour — it always came on spontaneously at the 
appointed time. 



vr 



142 OF LABOUR. 



CHAPTER XII. 



OF LABOUR, 



480. Whatever uncertainty may exist as to the efficient cause of 
labour, we are taught by long experience, that about the fortieth week 
of gestation, there is, for the most part, a painful effort made by the 
uterus to expel its contents ; and this effort is called labour. This 
event rarely takes place so suddenly, or so silently, as not to present 
a very regular series of phenomena, which, from their universality, 
must be considered as constituting a part of this process ; and some 
of them, perhaps, must be looked upon as essential to its well per- 
formance. The appearances to which I allude may be divided, 1st, 
into those which affect the system at large ; as rigors, and a number 
of what are denominated nervous symptoms; 2dly, into those which 
affect certain portions of the system independently of the uterine; as fre- 
quent inclination to make water, or a suppression of it, and tenesmus ; 
3dly, into those which affect the uterus in particular ; as the subsiding of 
the uterine globe ; the secretion of mucus ; the dilatation of the mouth 
of the uterus, and its alternate contractions. 



Sect. I.— 1. Of Rig or 's, fyc, 

481. It is a very usual thing, especially with nervous women, to 
be seized with rigors of more or less severity, in the very commence- 
ment of the silent preparations for, or during the more evident pro- 
gress of the labour. These shiverings, or rather, tremblings, are never 
attended with a reaction of the system ; and therefore, must not be 
considered as ushering in fever. These rigors would seem to be con- 
nected in some manner with a dilatation of the os uteri; and occur 
most certainly where this is rapidly performed. Nor do I at this mo- 
ment recollect an instance of rigor taking place where the os uteri was 
not more or less dilated. One of the most remarkable examples of 
this kind I recollect to have witnessed, was with a lady who awoke 
with a smart rigor from a sleep, and who every moment expected her 
labour to commence. The nurse became* alarmed, and I was imme- 
diately sent for. When I arrived I found her still trembling very 
severely, but had not experienced any symptom of labour- — she assured 
me, that nothing was the matter with her, except what I was witness- 
ing, namely, an agitation of the whole body, which she could not, by 
any effort, control. It was an extremely cold night, and I had ap- 
proached the fire ; but I had not been there five minutes before my 
patient exclaimed, she believed her labour was coming on ; and this 



FREQUENT INCLINATION TO MAKE WATER, &C. 143 

really was the case, and 60 rapidly, as not to give me time to place 
her in a proper situation for delivery ; she was delivered in less than 
five minutes from the time she first called my attention to her. 

452. When these tremblings take place later in the process, I have 
always felt assured die mouth of the uterus was dilating or dilated. 
They sometimes occur immediately after labour. And, so far as I 
have witnessed, they have never been attended by the sensation of 
cold. Nor have I ever known them do the slightest injury : though 
the patient and her friends are oftentimes so much alarmed, as to 
commit an error, by giving stimulating or heating drinks, &c. — in a 
word, they require no attention. 

453. Besides the rigor I have just mentioned, we sometimes see 
a number of nervous, or hysterical symptoms, attend the progress of 
labour ; especially with the first child if the process be rather slow — 
such as a disposition to cry, a sense of suffocation or choking, palpi- 
tation of the heart, <Scc. ; all of which, however, are almost sure to 
disappear so soon as the labour becomes active, and the pains, suc- 
ceed each other quickly. Should they be violent, a little of the tinc- 
ture of assafoetida, or Hoffman's anodyne liquor may be advantage- 
ously administered. Under such circumstances, we should give the 
patient every reasonable assurance of a happy termination of her suf- 
ferings ; and that there is nothing uncommon in her situation. It must 
not, however, be understood, that we are to pay no attention to these 
symptoms ; if they persevere, and are attended with a sensation of 
cold, we are to address the proper remedies for this purpose. 

Sect. II. — 2. Frequent inclination to make Water , Tenesmus, fyc. 

454. The uterus, even in the commencement of labour, if the fun- 
dus and body of this organ act healthily, is very often found so low 
in the pelvis, as to press upon some portion of the bladder ; but es- 
pecially, upon the neck ; this pressure excites a frequent inclination 
to make water ; in obeying which, the woman always suffers more or 
less inconvenience. Under such circumstances, the urine is very fre- 
quently driven from the bladder in small quantities, by every contrac- 
tion of the uterus ; this often leads the patient and her friends to be- 
lieve that the liquor amnii is escaping. This, I think, more frequently 
happens where the os uteri opens reluctantly ; and where the pains 
are pretty frequent and severe — it needs no application, unless the in- 
clination cannot be obeyed, and it amount to retention: in such case, 
the catheter must be introduced ; nor should this condition be suffered 
to remain too long without being relieved by this instrument. This 
retention, so far as I have witnessed, never takes place but in pro- 
tracted labours, and especially in such as may require artificial means 
for their relief. It should never be a rule to inquire frequently into 
the s;ate of the bladder in all cases of tedious labour ; and should 
the patient have been several hours without passing urine, the cathe- 



144 OF THE SUBSIDING OF THE ABDOMINAL TUMOUK. 

ter should be employed; and particularly, if there be no prospect 
that the labour will terminate speedily. Much present inconvenience, 
and sometimes lasting mischief, have arisen from the neglect of this 
precaution. I have seen this disposition continue for days after deli- 
very, and relieved only by the occasional use of the catheter. I have 
known an opening take place between the urethra and the vagina by 
the part sloughing ; and this in consequence of long pressure ; and 
witnessed an incontinency of urine from the same cause. 

485. In a case of the latter kind I was once consulted by my friend 
Dr. William Harris, in which entire relief was procured by the use of 
the tincture of cantharides. In this patient the stilicidium of urine 
was so constant as to lead to the suspicion there was an artificial 
opening from the urethra ; but a careful examination could detect no 
such state. I think this lady has had a child since that period with- 
out this accident being renewed ; but of this I am not certain. 

486. It is not unfrequent, at the commencement of labour, for the 
bowels to be several times moved in pretty quick succession, accom- 
panied with a strong effort or tenesmus ; or this inclination may take 
place after the labour is advanced, from the mechanical pressure 
the rectum suffers from the loaded uterus completely occupying 
the vagina. In the first case, should there appear to be suffi- 
cient time to permit its operation, a full dose of castor oil will be suf- 
ficient to remove it — should there not be time, five-and- twenty drops 
of laudanum will speedily quiet this inclination. In the last case we 
can offer no relief, unless the rectum be impacted with hardened feces, 
which do not escape from it, even by the repeated pressure of the 
child's head — when thus situated, an emollient injection will almost 
always procure relief. 



Sect. III. — 3. Affections of the Uterine System in particular, 

487. These last are of much more importance than those we have 
just been considering ; and most of them may be looked upon as 
almost always accompanying every healthy labour, and may be divi- 
ded into 

a. The subsiding of the abdominal tumour. 

b. The secretion of mucus. 

c. The dilatation of the os uteri. 

d. The alternate contractions of the uterus. 



a. — Of the Subsiding Abdominal Tumour. 

488. When the uterus and pelvis are in a healthy condition, the 
fundus at the last period of utero-gestation, is found little or no higher 



THE SECRETION OF MUCUS. 145 

than at the eighth month ; the reasons for this are, first the constant 
tendency which the body and fundus have to contract after the seventh 
month, forces the uterine contents lower into the pelvis ; and secondly, 
the effect of these contractions upon the neck of this organ, causes it 
to unfold, and thus furnishes additional room for the increasing foetus. 
In consequence of the development of the neck, the uterine contents 
must necessarily sink lower into the pelvis even without the agency 
of the contractions just spoken of; but especially when these take 
place in a healthy and natural manner. The existence of these con- 
tractions can be ascertained by the introduction of the finger into the 
os uteri, and placing its extremity gently against the membranes ; when 
thus situated, they will be found to be alternately relaxed — (Baude- 
locque) the effect of these contractions will be the obliteration of the 
neck of the uterus, and eventually producing labour itself. 

489. The sinking of the uterus into the pelvis (the old women 
call this falling) has been justly considered a favourable circum- 
stance; as it would seem to declare two important facts: 1st. A 
healthy condition of the uterus itself; and 2d. A healthy conforma- 
tion of the pelvis. 



b. The Secretion of Mucus. 

490. This important discharge almost always takes place, even 
before other symptoms declare labour to be at hand. Its formation 
is the result of one of the numerous sympathies to which the uterine 
system lays claim. It is always a welcome harbinger to the ac- 
coucheur, as it almost always foretells the condition of the parts, or 
ensures a favourable disposition in them to relax ; and this disposition 
is, caeteris paribus, almost in proportion to the quantity secreted. 
When it does not appear in the beginning of labour, even where the 
pains are frequent and severe, we rarely find upon examination, es- 
pecially with a first child, that the labour has progressed much, or 
that the os uteri is well dilated. But if a quantity be quickly se- 
creted, even very soon after we have made an examination, it will 
be found that the orifice of the uterus has suddenly undergone a 
change, by being, either perhaps well dilated, or easily dilatable : 
hence, we infer, it is in some way or other connected with, or instru- 
mental to, this process. 

491. This discharge is frequently tinged with blood; this colour 
is derived from the rupture of some small blood vessels of the chorion, 
or perhaps of the placenta. When not tinged with blood, it much 
resembles the white of an egg. Dr. Denman calls it an increased 
secretion of the fluid natural of the parts; but to this it does not ap- 
pear to bear the least resemblance — and if it be even furnished by 
the same vessels, it must be by an altered action of them. 

492. The formation of this fluid answers two important ends : 1st. 
It lubricates the vagina, which permits the fcetus to pass more easily ; 



146 THE SECRETION OF MUCUS. 

2d. It acts as topical depletion from the neck of the uterus, vagina, 
and perinseum ; and thus facilitates their relaxation. This last cir- 
cumstance I consider to be the chief use of this discharge ; for were 
it confined to the mere lubrication of the passage, its utility would 
be much more limited than it is found to be ; for this end could be 
answered very well by artificial means ; but these, it is well known, 
are not so efficient. 

493. The writers on midwifery have too much limited the useful- 
ness of this discharge: they look upon it as a mere lubricant; and 
carefully caution against too frequent touching, lest, say they, it should 
remove this substance from the vagina, and thus give rise to more 
friction between the child's head and the soft parts of the mother. 
Now, were this the only evil to be apprehended by incautious or un- 
necessary touching, it could be easily remedied by any mild unctuous 
substance ; but,- as I have just observed, it is well known, though not 
acknowledged, that this substitute by no means answers the purpose 
for which I believe this discharge was instituted. 

494. By frequent and incautious touching, the parts immediately 
exposed to the finger are over-stimulated, and incipient inflammation 
very often ensues, which clearly shows how reprehensible such con- 
duct is. The glands furnishing this fluid are over-stimulated, nay 
sometimes become inflamed. In this case the secretion ceases, and 
the parts become tender and swollen ; especially the mouth of the 
uterus, should it not be fully dilated ; the pains are less frequent, and 
less protrusive ; the woman is restless, and enjoys no calm in the in- 
tervals of the pains; fever is excited; headach, thirst, and a hot skin 
follow: in a word, a new condition of the system arises, and almost 
suspends the business of labour. It would be in vain, under such 
circumstances, to offer a substitute for the absent mucus, by present- 
ing to the parts any unctuous, or mucilaginous substance whatever: 
it can only be recalled by rest, and free blood-letting. To the latter, 
we must have immediate recourse, if we wish to subdue the unne- 
cessarily provoked inflammation ; and to restore the uterus to the re- 
enjoyment of its suspended powers. In many cases like those just 
mentioned, I have seen this remedy act with the certainty and promp- 
titude of a charm. This intention is very much aided by throwing 
up the vagina, by means of a syringe, a rich infusion of flaxseed, or 
slippery elm bark tea ; and these substances may be substituted for 
the hog's lard, or sweet oil, which are in general use for the purpose 
of lubricating the parts. 

495. The disturbance excited throughout the system when the 
vaginal surface becomes inflamed, distinctly shows the important role 
this mucous secretion performs in the economy of labour ; it demon- 
strates that it is instituted for a much higher purpose than merely to 
lubricate the parts : it shows clearly, that its formation is in some 
way or other connected with the dilatation of the os uteri, and the 
relaxation of the perinseum: let us beware, then, how we interrupt 
its formation, by rude and uncalled for handling. 



THE CONTRACTION OF THE LONGITUDINAL FIBRES. 147 



c. — Of the Dilatation of the Os Uteri. 

496. All writers upon midwifery, make this important operation 
the effect of mechanical impulse ; though many of them, at the same 
time, are forced to acknowledge they have seen it dilate, where 
neither the distended membranes nor any portion of the child has 
entered its circle, to effect its opening by a wedge-like action. That 
the waters distending the membranes, and the child itself, when 
powerfully impelled by uterine contraction, may occasionally have an 
influence on this operation, I am not disposed to deny; but if this take 
place, it does not open this part either so easily, so kindly, or so ef- 
fectually, as when this is achieved by the powers destined for this 
purpose. Before I offer a different explanation of this phenomenon, 
it will be necessary to consider the different kind of contractions per- 
formed by the uterus : they are — 

497. a. The contraction of the longitudinal fibres of this organ. 

b. The contraction of the circular fibres. 

c. The simple contraction. 

d. The compound contraction. 

e. The tonic contraction, and its effects. 

f The spasmodic, or alternate contraction, and its effects. 



a. — The Contraction of the Longitudinal Fibres. 

49S. By the longitudinal fibres of the uterus,! wish to signify those 
fibres upon the contraction of which the uterus is shortened from 
fundus to mouth; and this will be in proportion to the effort. The 
effect of this contraction is, to make the contents of the uterus ap- 
proach its mouth ; as this, from its organization, must necessarily be 
the least resisting part, this tendency will be constantly in proportion 
to the diminution of resistance,* and the force with which these fibres 
act. It will be perceived, that if the uterus be diminished in length, 
it would, necessarily, be increased in breadth, unless opposed by the 
circular fibres ; or in other words, the circular fibres would be put 
upon the stretch, until the diminished length be compensated, did 
they not resist this violence, by being stimulated to contraction, by 
the uterus becoming shorter from fundus to mouth by the contraction 

* The duration of labour will, therefore, almost invariably depend upon the resist- 
ance of the circular fibres of the mouth of the uterus, (all things being equal.) It is 
evident to every experienced accoucheur, that the c rcular fibres constituting the mouth 
of the uterus have different degrees of disposition torelaxj when acted upon by the con- 
tracting body and fundus; in some instances the long continued efforts of the body 
and fundus are required ere they yield ; while in others, contraction scarcely takes 
place before they give way, and permit the presenting part to pass freely ; nay, some- 
times rapidly. 



148 OF THE SIMPLE CONTRACTION. 

of the longitudinal fibres, and which necessarily tend to distend the 
uterus in its transverse direction. But being thus excited to action, 
the two sets of fibres urge the contents of the uterus towards the least 
resisting part of itself, namely, the mouth; by which means the mem- 
branes become distended, and lengthened in the direction of the lon- 
gitudinal axis of this viscus, nearly as much as this set of fibres 
shorten themselves. The action of the longitudinal fibres is at right 
angles with the circular ; and has a tendency to oppose, or overcome 
the disposition of the circular fibres to narrow the uterus in its trans- 
verse direction. _ 



b. — The Contraction of the Circular Fibres, 

499. By the circular fibres 1 mean those which are arranged trans- 
versely from the mouth of the fundus, and which* by contracting, 
diminish the capacity of the uterus in the direction of the transverse 
diameter; and should they act alone, and the os uteri be closed, they 
would necessarily stretch the uterus in the direction of its vertical, or 
longitudinal diameter. These fibres, as we have said, may be con- 
sidered as running round the uterus, from the fundus to the termina- 
tion of the neck ; they have, as I shall attempt to prove presently, 
but an indirect agency in farthering the expulsion of the uterine con- 
tents ; the action of the circular fibres, especially at the neck of the 
uterus, is almost in direct opposition to the longitudinal, and serves 
rather to retain than to expel the contents of the uterus. It is by 
the successful and uniform contraction of the circular fibres, and es- 
pecially those which compose that portion of the uterus, properly 
termed the neck, in the unimpregnated, or the undeveloped state of 
the uterus, that the woman is enabled to carry the produce of con- 
ception to the full period of utero-gestation. They may act inde- 
pendently of the longitudinal fibres ; or they may act with greater 
force than they, though acting simultaneously with them, as I shall 
have occasion to remark by and bye. 



c. — Of the Simple Contraction. 

500. When either the longitudinal or circular fibres act alone, 
" The simple contraction " takes place. It may be asked what evi- 
dence have we that one set of fibres can act independently of the 
other ? I answer, of this we have abundant proof in the contractions 
which take place toward the latter period of gestation, and of which 
we are made sensible, by passing the finger, as already mentioned, 
(488) within the os tineas, and placing its extremity against the mem- 
branes — a tense and relaxed condition of the membranes is per- 
ceived : this is owing to the longitudinal fibres acting alone, for did 
the circular act at the same time, it would be felt by the finger, by 



OF THE TONIC CONTRACTION AND ITS EFFECTS. 149 

the edges of the os uteri stiffening or becoming rigid ; but this is not 
the case. On the other hand we prove that the circular fibres may 
contract firmly, and for a long time, without the slightest co-opera- 
tion of the longitudinal fibres, by the well known circumstance that 
when the waters have been discharged for some time, the uterus is 
found to embrace the body of the child firmly : in this case it is evi- 
dent that the circular fibres contract alone, as there is no effort to ex- 
pel the child, as would be the case, did the longitudinal fibres exert 
an influence at the same time. 



d. — Of the Compound Contraction. 

501. This contraction is the effect of both sets of fibres acting si- 
multaneously ; this is proved by the mouth of the uterus attempting 
to close itself during the period of action, and by the head, or pre- 
senting part, evidently sinking lower, (though, perhaps, to rise again 
immediately,) in the pelvis. Now, these two circumstances could 
not happen at one and the same time, did not both sets of fibres con- 
tract together ; it is this compound action which attends the com-* 
mencement of all healthy or regular labours. 



e. — Of the Tonic Contraction, audits Effects, 

502. The tonic contraction, or that contraction which tends to di- 
minish the uterus in all directions, (250) cannot be called into action 
to any extent until the uterus is either in part, or altogether deprived 
of its contents;* but if this happen even in a small degree, the whole 
of the fibres of which the uterus is composed being to shorten, or fold 
themselves up, and thus make the uterus accommodate itself to the 
quantity and almost the shape of its contents. In consequence of this, 
the direction, and, perhaps, the size of the blood vessels of this organ 
are changed ; and, though in no very sensible degree at first, or when 
its contents are but little diminished, yet it will be found that the 
changes will bear an exact proportion to the evacuation from the 
uterus. It is this contraction which preserves the woman from fatal 
hemorrhage, when the placenta is either partially or altogether de- 
tached ; it serves also the important purpose of keeping the uterus in 
constant contact with its contents, and enables its fibres to act with 
more efficiency upon the body to be expelled ; it is also this contrac- 
tion which opposes the re-distention of the uterus, and so obstinately 
does it do this sometimes, that turning is rendered impracticable. 

* Whatever will weaken the force of the uterus, or diminish the quantity of its con. 
tents, will permit, in that proportion, the tonic contraction of the uterus to take place, 
if this organ b« in a healthy condition; even a less quantity of blood in tin parfete*. 
or a very partial dilatation of the 03 uteri, or tiic escape of a very small quantity of ihf 
liquor aranii, will do the same, 

u 



150 SPASMODIC OR ALTERNATE CONTRACTION, &C. 



f. — Of the Spasmodic or Alternate Contraction, and its Effects. 

503. This contraction is often called the spasmodic contraction ; 
but I prefer, as I have already observed, (254,) the term alternate 
or periodical contraction; for it is not necessarily accompanied with 
pain.* 

504. The cause of these contractions, like the contractions of every 
other muscle, must be a stimulus of some kind or other. I have al- 
ready declared (161,) my ignorance of the nature of the stimulus that 
excites the uterus to contraction at the end of nine months ; though 
we are very often enabled to detect it before that period ; for it is 
always found, that whatever can stimulate this organ to a certain de- 
gree, is capable of provoking its action : and if not interrupted by 
proper counter-agents, it goes on until the contents of the uterus are 
expelled. So much for the causes which may excite the uterus to 
action ; but w T hat is it that gives these contractions their alternate or 
periodical form ? So far as I know, a solution to this question has 
never been given ; indeed, I am not certain it has ever been asked ; 
therefore, if I Tail to be satisfactory in the one about to be offered, it 
must be remembered I only hazard a conjecture ; and it will but share 
the fate of thousands upon every subject, from the time of Hippocrates 
to the present moment. 

505. In order that a muscle may renew its contraction, it must 
be elongated by some antagonizing power, after it has become re- 
laxed; in almost every part of the body this power is at once dis- 
coverable ; but where, and in what resides, that which enables the 
uterus to repeat its efforts ? I am of opinion this power depends upon 
its own structure and economy — I shall now attempt to prove this. 
The uterus, by impregnation, becomes of course distended, in pro- 
portion as that process advances — it is, therefore, elongated, or its 
fibres put, to a certain extent, upon the stretch, they are thus enabled 

* The alternate pains must not be confounded with the severe and distressing- pain 
in the back ; this pain, where it exists, (for it is not constant, as we have seen a num. 
ber of instances in which it has not taken place,) is sometimes more distressing than 
that caused by uterine contraction. It is difficult to account for this pain ; some have 
attributed it to the stretching- of the posterior ligaments of the uterus; others, to the 
violent contraction of the muscles of the posterior part of the trunk, &c. Neither of 
thesii causes appears to be sufficient to account for this symptom. We are of opinion 
it is caused by some irregular action of the uterus itself; perhaps the posterior plains 
of fibres, as we have very often seen it relieved by the exhibition of ergot. Madame 
Boivin says this pain never takes place but when the head presents ; or when the head 
has passed the superior strait, there is no pain in the back ; or when the head'is engaged 
in the superior strait, or sometimes when in the excavation of the sacrum, when the 
uterus had not begun to dilate, or after the head has performed rotation the pain 
ceases. So, also, if either the first or fourth presentation exists, the pain will be con- 
fined to that part of the back which corresponds with the right lateral portion of the 
sacrum ; and when the second or fourth obtains, it will be felt in the left side of the 
sacrum. This pain, however, ceases generally after the escape of the waters, provided 
this takes place when the labour is pretty well advanced ; for if this happen very early 
in the labour the pain is more certain to take place, and is of greater severity. 



SPASMODIC OR ALTERNATE CONTRACTION, &C. 151 



to contract as soon as the appropriate stimulus is applied. What is 
the effect of this contraction ? An approximation of the uterine fibres; 
a compression of all its blood vessels, with the immediate discharge 
of a large portion of blood from them into the general system ; in con- 
sequence of this, the uterus becomes paler and the vessels empty, or 
nearly so. The blood escapes by means of this contraction quaqua- 
versum ; and, to facilitate its departure, the anastomoses between the 
arteries and veins are unusually frequent ; and the latter vessels are 
not furnished with valves. 

506. What is the effect of the subsequent relaxation ? The fibres 
of the uterus become longer, straighter, and more easily distensible ; 
the large vessels and sinuses are less compressed, and consequently 
will now permit the natural resiliency of their coats to act — while the 
influent blood will suddenly fill them, and thus restore the equilibrium 
which the previous contraction had destroyed — now, this rapid influx 
will not only distend the empty vessels, but will also prove a powerful 
stimulus to the uterine fibres ; and thus urge them to renew their con- 
traction ; and this will be repeated from time to time, until there be 
no farther necessity for its continuance. This plethoric state of the 
uterus, if we may so term it, is proved by the heightened colour of its 
parietes. 

507. I presume when this contraction is best performed, it is chiefly 
by the exertion of the longitudinal fibres. 

508. This opinion is founded upon the relative strength of the two 
sets of fibres. I believe that the longitudinal fibres or those which by 
contracting shorten the uterus, are the stronger of the two ; and for the 
following reasons: 1st. Because, if they were of equal strength, deli- 
very could not take place ; as the circular fibres by the contractions, 
would rather, embrace and retain the child, than advance it ; since 
they tend to diminish the transverse diameter of the uterus; and con- 
sequently, their .action is, as I have already observed, (498,) at right 
angles with the action of the longitudinal fibres. 2d. When either 
the absolute, or relative strength of the circular fibres is increased by 
any cause whatever, labour does not advance ; therefore, the circular 
fibres do not directly contribute to the expulsion of the child. 3d. 
As the circular fibres do not, from the very nature of their action, 
contribute to the immediate propulsion of the child, as just declared, 
they must be considered inferior in power to the longitudinal fibres ; 
since the child is expelled without their direct agency — therefore, the 
latter set of fibres has not only to move the child, but to overcome 
the resistance the former gives, by the direction of their action. We 
see this finely exemplified in those cases where the waters have been 
discharged early, and the uterus closely embraces the child ; and 
where, by virtue of its tonic contraction, it even accommodates itself to 
the inequalities presented by the child's body; in such instances, 
labour would be stationary, did not the longitudinal fibres possess 
.greater power than the circular. 



152 THE MANNER IN WHICH THE OS UTERI IS OPENED. 

CHAPTER XIII, 

THE MANNER IN WHICH THE OS UTERI IS OPENED. 

509. With these facts before us, I shall attempt the explanation 
Of the dilatation of the os uteri. At the full period of utero-gestation, 
the process called labour must take place, that the womb may expel 
its contents ; to this important end, its body and fundus must contract, 
While its neck must dilate — the question now is, how is the latter 
effected ? During the whole period of gestation, the lower part of the 
"womb is kept closed by the contraction of its circular fibres : this con- 
traction of the circular fibres must now be overcome by the exertions 
of the longitudinal ; therefore these two sets of fibres may, without a 
strained comparison, be considered as antagonizing powers. During 
gestation, at least until the seventh month, the longitudinal fibres yield 
much more willingly than the circular, to the distending force of the 
increasing ovum ; this may be owing to their greater length, or their 
greater laxity; and hence, perhaps, the lengthened form of the uterus. 
This stretching must have a limit, or a maximum ; and when this 
arrives, they will necessarily be stimulated to contraction ; and this 
"really takes place at this period, as I have several times declared, and 
attempted to prove, (488, 500.) Now, the effect of this effort, which 
is almost constantly repeated after it is once commenced, is felt by 
(until now,) the passive neck of the uterus ; and obliges it not only to 
support the action of the body and fundus, but also the weight of the 
child and waters; these joint powers make it unfold itself, and to be- 
come identified with the other portions of the uterus ; so that, at full 
time, it forms a portion of that globe which is placed in the cavity of 
the pelvis ; and its distinctive mark, or projection, is lost in the uni- 
form surface presented to the finger. 

510. From the moment the neck begins to be operated upon, it 
begins to lose in thickness, and in length— and these changes com- 
mence at that part next to the body of the uterus ; so that the extre- 
mity of the neck, or the os tinea?, is the last portion which is effaced. 
"When the longitudinal fibres act, the circular become a little stretched, 
in consequence of the length of the uterus being diminished ; and I 
have already said (498,) that the uterus cannot diminish in one direc- 
tion while the membranes are entire, without increasing in another ; 
and this must be the case so long as the mouth of the uterus remains 
shut : but this cannot be very long, as it is obliged to sustain the whole 
pressure of the contents of the body of the fundus, and this in pro- 
portion to the power with which the longitudinal fibres may contract, 
as well as the force exerted by a part of the circular fibres, which are 
now called into action, by the contraction of the longitudinal disten- 
ding them, until they themselves contract from this very stimulus. 



THE MANNER IN WHICH THE OS UTERI IS OPENED. 153 

511. This action and re-action are reciprocated for some time ; the 
longitudinal fibres shortening the uterus from fundus to mouth ; while 
the circular attempts to resist the effect of their action, by contracting 
themselves, and thereby opposing the tendency to distention in the 
transverse direction of this body — the effect of this compound action 
is to direct the body to be moved towards that part which offers it the 
least resistance ; and this is the small opening called the os uteri — the 
fibres which immediately surround this opening, and oppose its imme- 
diate dilatation, gradually become weakened by the superior strength 
and persevering action of the longitudinal fibres ; and after a contest 
of more or less severity and duration, they yield : and in their quies- 
cence, the dilation of the os uteri consists. 

512. In the whole of this arrangement, we do not see a necessity 
for the mechanical wedge-like agency of the membranes on the circle 
of the os uteri, which Dr. Denman* speaks of as important to its dila- 
tation — for every day's experience proves that the most perfect and 
speedy relaxation of the mouth of the uterus takes place, without any 
such influence. Indeed the doctorf seems to yield this point when 
he confesses that " in many cases the membranes break spontaneously 
long before this period (that of the os uteri being wholly dilated ) 
without any material inconvenience." Besides, we see the same re- 
laxation take place where the pelvis is so much deformed, that it is 
impossible for this mechanical arrangement to take place, as the os 
uteri cannot become the depending part, or be in the axis of the su- 
perior strait. 

513. If it be asked, why are those labours in which the membranes 
give way early, always more tedious and painful, than those in which 
they are preserved ? 

514. I would answer, that this is not by any means always the case ; 
and that when the membranes have yielded from their delicacy before 
the genuine expulsive action has commenced, the uterus may be said 
to be surprised, (if I may use the expression,) into contraction, before 
the natural stimulus is given. In consequence of this, the uterus is 
made to embrace the child closely, by virtue of its tonic power, and 
is sometimes, by this event thrown into irregular and painful contrac- 
tions, by the unequal surface which the child's body presents to its 
internal surface — for the evacuation of the waters prevents the lower 
part of the uterus from being fully stretched by the contractions of the 
body and fundus ; and by this means, retards the weakening of the 
circular fibres at this part; a circumstance of considerable moment to 
the dilatation of the os uteri. If an unusual degree of pain be excited 
by the premature escape of the waters, it is not because the membranes 
and waters fail in their wedge-like agency to dilate it; but because 
the uterus is prematurely excited into action ; and of course, before 
all the terms of pregnancy have been complied with — as the waters, 
while retained, serve to ensure an equal distention of that part of the 

• Introduction, Francis's ed. p. 278. t Idem, p. I 

14* 



164 THE MANNER IN WHICH THE OS UTERI IS OPENED. 

litems, which we have agreed to call, in the unimpregnated state, its 
neck, and is the part which is to relax during labour, that the child 
may escape from the general cavity of this organ. 

515. I am abundantly confirmed that this is the true explanation; 
for, by the fact, if the waters have not prematurely passed off; or, in 
other words, if at the time of their escape, the uterus is prepared for 
the regular routine of labour, the mere circumstance of their evacua- 
tion, (casteris paribus,) will neither materially retard the dilatation of 
the os uteri, nor necessarily create unusal delay to delivery — of this, 
we have additional proof from Dr. Denman, as just quoted. But in 
this admission, let it be recollected, that I consider the waters as useful 
by their equal pressure upon the lower part of the uterus, and by dis- 
tending, and the same time, by the same agency, weakening, the cir- 
cular fibres of this part ; and thus indirectly favouring the dilatation of 
the mouth of the uterus. 

516. I may, therefore, I believe safely lay it down as a general 
rule, that the early spontaneous rupture of the membranes does not 
directly or necessarily produce a more painful or tedious labour, 
unless uhe uterus is from this cause immediately excited to con- 
traction ; for should pain not follow very soon, or should the legiti- 
mate pains of labour have preceded this accident, the labour will, 
all things being equal, be as in ordinary cases ; for I have many 
times seen patients, with whom the first intimation of labour being 
at hand, was a discharge of the liquor amnii; but this not instantly 
followed by pain; but when the pain did come on, the labour was 
speedily finished — in these instances, the mouth of the uterus opened 
speedily, and as extensively as though the membranes had not given 
way, and the waters had not discharged themselves. 

517. Let any one who has made the attempt to penetrate the os 
uteri when rigid, be asked, if a direct action on its edges by the 
hand formed in a wedge-like shape, and the application of con- 
siderable force will always be sufficient to overcome the opposition 
of the circular fibres of the neck 1 He will answer, if he be candid, 
No; and will add, that the part would suffer laceration rather than 
yield to the force employed. Is it reasonable then, to expect that a 
wedge formed by the smooth, and comparatively delicate mem- 
branes, with the liquor amnii within them, will as a mere mechani- 
cal power, however aided by a strongly contracting body and 
fundus, achieve more than the well-directed force of the hand as 
just stated ?* Let any one familiar with the general manner in 
which the distended membranes offer themselves at the orifice of 
the uterus during pain, be asked if their presence and agency, at 

* Besides, every accoucheur knows, that in many instances of the most speedy and 
perfect dilatation of the os uteri, the membranes are too feeble to bear the slightest 
force. The mere touch of the finger will sometimes rupture them; and this at the 
moment the os uteri is yielding 1 rapidly. Now, in such cases, the dilatation of the os 
titeri should cease, as soon as the membranes had yielded, if their presence were me- 
chanically necessary to this end : especially, fa p rtion of the child have not engaged 
in the mouth of the uterus, to supply the place of the distended membranes. 



THE MANNER IN WHICH THE OS UTERI IS OPENED. 155 

such a moment, presents to his mind the idea of a mechanical 
power, attempting to overcome the resistance offered by the con- 
traction of the circular fibres? and, I am sure, he would unhesi- 
tatingly say, No. 

518. When the os uteri does dilate, it is not by its edges being 
stretched mechanically — it is an absolute inability in the circular 
fibres to maintain a state of contraction, and, for the time being, 
may be considered as paralyzed, or excessively fatigued — or, per- 
haps, more properly speaking, it is the relaxation of a sphincter not 
subject to the control of the will. 

519. I admit, that the os uteri is sometimes forced to open in a 
degree, by ihe membranes, or the presenting part engaging in its 
circle when these parts are strongly impelled by the contractions of 
the body and fundus; but, when this happens, the orifice does not 
present the same feel as when it dilates by the regular, and natural 
process. It is evidently perceived that it is reluctantly yielding to 
force, and is not obeying a law. 

520. When labour is most easily, and naturally performed, there 
appears to be a tacit understanding, if we may be allowed the ex- 
pression, between the longitudinal and circular fibres; the latter re- 
lax suddenly, and extensively, while the former contract so silently, 
but so effectually, that we cannot discover the agencies by which 
this is effected — who has not witnessed the almost instantaneous 
opening of the os uteri? who has not been sensible of the retraction 
of its edges over the child's head, and the delivery of the child fol- 
low almost at the same moment? 

521. To the explanation just given of "the manner in which the 
os uteri becomes opened," it is objected, " that if a muscular part is 
suddenly extended, its contractile powers are brought into violent 
action ; but let the part be extended gradually, as is of course the 
case where the extension depends upon the slowly increasing size 
of the ovum, and when it has arrived at its * maximum of stretching' 
its antagonistic powers appear to be destroyed ; for contraction 
either does not take place at all, or very imperfectly. It is well 
known that surgeons act upon this principle, when they have to 
overcome the obstinate contraction of muscles ; they exhaust the 

Sowers of the part, by keeping up a gradual extension." (Lond. 
led. and Phys. Jour, for August, p. 143.) 

522. The objection just stated is ingenious, but not valid : 1st, 
because there is no analogy between the inordina:c stretching of a 
muscle not organized for this purpose, and the expansion of the 
uterus, to which this capacity is most amply given ; 2d, that a period 
must arrive, in the stretching of even the common muscles, however 
gently performed, at which they would contract, and that violently, 
if permitted from the stimulous which "extension" must oner; and 
it is precisely so with the uterus — its organization is such, as to 
support a great deal of distention, before it is like the common 
muscle, stimulated to contraction ; 3d, the bladder is gradually dis- 



156 CONDUCT DURING LABOUR. 

tended, by the percolating urine, until its parietes are put upon an 
easy stretch ; it then gives warning, that it can no longer support 
this state with impunity ; for the distention has arrived at its healthy 
" maximum," and must not be carried farther ; 4th, that were the 
bladder, or the uterus itself, suddenly stretched to the extent of their 
capacity, they would as certainly lose the power of contraction, as 
the muscles over which the surgeon exerts his control. 



CHAPTER XIV. 



CONDUCT DURING LABOUR. 



523. In the management of labours much judgment and caution 
are required, that a simple and natural case may not be converted 
into a laborious and dangerous one. Ill-directed measures will al- 
ways have penalties attached to them ; and it is only by taking a 
proper view of the nature of the labour, that it can be conducted to a 
happy issue. There is no one circumstance, that so largely and certainly 
contributes to divert nature from her proper course, as the persuasion 
that art can always benefit her — hence, the constant employment of 
ill-directed manoeuvres by an ignorant accoucheur, or midwife. And 
unfortunately for the interest of humanity, it requires more knowledge 
not to be officious than falls to the share of many of those, who pretend 
to practise midwifery. It is a vulgar prejudice, that great and con- 
stant benefit can be derived from the agency of the accoucheur; espe- 
cially during the active state of pain ; and this feeling is but too often 
encouraged by the ignorant and the designing, to the injury of the 
patient, and to the disgrace of the profession. When all things are 
doing well, the active duties of the accoucheur are limited indeed — 
it is but where the contrary obtains, that he can be said to be posi- 
tively useful ; but to discriminate between the two conditions, re- 
quires a thorough knowledge in what a healthy labour consists ; and 
this can only be known with certainty, by him who is well-grounded 
in the principles of his profession, and who has enjoyed an extensive, 
or, at least, a well-directed experience. 

524. To conduct a labour with safety, the practitioner should be 
well acquainted with its phenomena ; the order or succession of them ; 
be able to decide, when certain of them are wanting, or when others 
are in excess ; to estimate the relative or positive importance of such ; 
the force or effect of each pain ; the necessity of preserving or of 
wasting the waters ; the degree of resistance the os uteri, or external 
parts may offer ; the situation of the former, as regards the presenting 
part ; the certainty of the presentation, both generally and specifically; 



CONDUCT DURING LABOUR. 157 

the mode of rectifying any error of presentation in proper time ; the 
capability of doing this with the greatest advantage to the patient and 
to the infant ; and " though last, not least" in importance, he should 
be able to pursue a firm, candid and feeling conduct throughout the 
"whole scene, that he may not be betrayed into indiscretion, by the 
overweening anxiety of the friends of the patient ; that he may not 
lose the important moment to act, from an apprehension that blame 
may attach upon the disclosure of its necessity ; and that the sufferer 
may derive every advantage his kindness and sympathy can afford. 

525. That man is but little used to the exercise of the social virtues, 
who is ignorant of the influence a kind and feeling conduct has upon 
his suffering patient — to her, it almost atones for the want of skill or 
experience : and to deprive her of it, is withholding a right for which 
nothing can compensate. 

526. She is entitled to all the consolation a well-grounded assurance 
of a happy termination of her sufferings can afford ; and this must be 
offered to her from time to time, that she may profit by its encouraging 
influence ; yet she must not be betrayed into false hopes, by an ill- 
judged promise of a speedy issue, when the period, from the very na- 
ture of the case, must be remote — nothing perhaps is so destructive 
to confidence, as ill-requited promises of this kind ; nothing so sick- 
ening to the heart, as " hope deferred." 

527. The young practitioner especially, should be very sparing of 
promises ; for it requires long experience to make them with any kind 
of certainty ; and until he possess this, they should be evasively given, 
that sad disappointment may not ensue. For a woman will support 
herself with much firmness, where relief is believed to be certain, 
though it may be distant, while she would flag, under the failure of 
often repeated promises of speedy relief.* Her mind should be kept 
as free from anxiety as the nature of her situation will permit; there- 
fore, no conversation should be indulged in, that might for an instant 
excite her apprehensions — conversation should be cheerful, and free 
from the idle discussions of danger in similar situations ; and it must 
be as void of levity as of gloom. 

528. To the well-bred gentleman, it would be almost an insult to 
say any thing on the score of decency ; but as errors may be uncon- 
sciously committed, it may be proper to suggest a few cautions upon 
this head that may be important to the welfare of the well-meaning, 
bat inexperienced practitioner. 

529. 1st. Let all communications to the patient of a delicate nature, 
be conducted through the medium of a third person ; the nurse, when 
present, should always be that person ; in her absence, an elderly 
friend. 

530. 2d. Endeavour, by a general and well-chosen conversation, 
to divert the patient's mind as much as possible from the purpose of 
your visit, when your services are not immediately required. 

* Denman. 



158 CONDUCT DURING LABOUR. 

531. 3d. "When your presence is not absolutely necessary in the 
sick room, be as little in it as will be consistent with your duty — by 
this you remove restraint ; and abridge to appearance the period of 
your watching. 

532. 4th. Should you judge it necessary to ascertain the situation 
of your patient, let the proposition be made by a third person, as the 
nurse ; let her declare the circumstances which lead you to believe 
it would be important ; such as the length of time the patient has been 
in pain ; the force and frequency of the pains ; the evacuation of the 
waters, if it have taken place ; and, above all, the necessity of ascer- 
taining the progress of the labour, and the nature of the presenta- 
tion. 

533. 5th. If, after you have made your examination, you should 
be importuned for your opinion of the nature of the presentation, and 
the duration of the labour, do not commit yourself by any positive 
declaration, unless you are certain of the first, and pretty sure of the 
latter. 

534. 6th. Before you proceed to the examination, let your patient 
be placed with the most scrupulous regard to delicacy, as the slight- 
est exposure is never necessary ; let the light be excluded from the 
room by closing the shutters if it be day, and by the concealment of 
it if it be night. So much for the regulation of the conduct of the 
accoucheur in his intercourse with his patient ; but it is also im- 
portant that we lay down some general rules by which he, and the 
patient shall be governed, during the progress of the labour. 

535. 1st. The patient is to be forbidden every thing which shall 
have a tendency to excite the system ; she will, therefore, be prohi- 
bited wine or any other liquor ; or even stimulating food. 

536. 2d. She should be directed to keep as quiet as possible; 
and the preposterous custom of obliging her to walk the floor with 
a view to increase the pains when tardy, should be peremptorily for- 
bidden. 

537. 3d. Inquiry should be made as to the state of the bowels ; 
costiveness should be removed by castor oil, magnesia, or any other 
mild cathartic, if there appears to be sufficient time for its operation ; 
if not, let it be effected by a simple injection.* 

538. 4th. Her dress should be such as to require no alteration 
after delivery ; therefore, her linen should be so placed, as to be 
out of danger of becoming wet from the discharges ; her petticoat 
should be without shoulder-straps, that it may be easily removed ; 
and a bed gown should protect the upper part of her body. 

539. 5th. The bed should be so arranged as to preserve it with 
certainty from the discharges ; for this purpose a blanket should be 
folded several times, and placed beneath the under sheet, at the part 
of the bed on which the woman will permanently lie ; a sheet as 
often folded should be placed over the under sheet, so as to corres- 

* A pint of warm water, and a table-spoonful of common salt is one of the best 



CONDUCT DURING LABOUR. 159 

pond with the blanket below ; on this the woman will be placed after 
delivery. 

540. 6th. The woman will be placed for labour upon her left side, 
at the foot of the bed, in such a manner, as will enable her to fix her 
feet firmly against the bed-post; her hips within ten or twelve inches 
of the edge of the bed ; her knees bent, her body well flexed upon 
the thighs ; this position will bring the head and shoulders near the 
centre of the bed : and pillows may be placed to raise them to a 
comfortable height — the part of the bed on which the patient is now 
placed, must, like the part on which she is permanently to rest, be 
secured by folded blankets placed over the under sheet. 

541. 7th. When the patient is about to be placed for labour, the 
practitioner should withdraw, and leave this arrangement to the 
nurse ; she should be covered entirely, except her head ; if in winter, 
by a blanket or coverlet ; if in summer, a sheet will be sufficient. 

542. 8th. When about to make an examination, choose the time 
of a pain for this purpose, and proceed to it with the most rigid ob- 
servance of delicacy. To the very young practitioner it may be 
well to observe, that the chair on which he is about to sit, should be 
so placed that his right arm should be next to his patient : if this 
be not attended to, his position will be both inconvenient and fa- 
tiguing. There is more in placing the chair rightly as I have directed, 
than would at first sight be imagined. I remember a case in point — 
a gentleman who was very desirous to see some obstetric practice, 
asked me as a favour, to send him some patients. This case occur- 
ring, and as he was well advanced in life, and a grave looking per- 
sonage, I sent him to the patient. The sober looking person was 
well received as my locum tenens, and every thing passed off favoura- 
bly. But it unfortunately happened for him, when the pains grew 
importunate, that it was necessary for him to make an examination ; 
he did this with so embarrassed an air, that it was remarked by one 
of the bystanders. I arrived at this time, and having examined the 
patient, was about to take my leave, and proceeded to the door for 
this purpose, when an old lady followed me out, and said, "you are 
not going to leave us with that inexperienced fellow, are you?" 
Why what makes you think him without any experience ? I do as- 
sure you he has seen practice before ; (which was the fact,) she gave 
me a look every way expressive of her distrust — she said "you are 
quizzing now, did I not see how he placed the chair!" He was not 
allowed to stay ; and I was obliged to attend, much to my discom- 
fiture. 

543. 9th. Do not remain with the patient longer than the state of 
the labour may make it necessary. That is, if it be not well ad- 
vanced, time should be given for its farther progress ; but from time 
to time, it is well to ascertain its condition ; but beware of officious 
and unnecessary touching, for the reason we have elswhere assigned. 
(494.) ' ' 

544. 10th. Should the pains be efficient, and the os uteri well di- 



160 OF THE NECESSARY DUTIES TOWARDS THE CHILD. 

lated, or even easily dilatable, and the membranes entire, let them be 
ruptured by the pressure of the finger against them, or, by cutting 
them with the nail of the introduced finger. We are well aware that 
this direction is very far from being in conformity with the opinions 
of writers upon this subject ; but we are sure we have not adopted it 
upon slight grounds, nor proposed it, because it might quadrate with 
preconceived notions. In directing it, we are certain that experience 
is altogether in its favour. And this should be done for the following 
reasons : first, because, when the mouth of the uterus is dilated, or 
even easily dilatable, the membranes have performed every duty they 
can perform ; secondly, that very often the advancement of the pre- 
senting part is retarded by the strength of the membranes, and the 
labour much protracted by it ; thirdly, that very frequently the pains 
are increased both in force and frequency, and the labour much 
abridged by it ; fourthly, it gives much greater security to the woman 
after delivery, by permitting the tonic contraction to take place before 
it is accomplished, and thus ensuring a more speedy delivery of the 
placenta, and also very much lessening the risk of after-hemor- 
rhage. 

645. 11th. When the head is emerging from under the arch of the 
pubes, the perineal tumour should be carefully supported by placing 
the palm of the left hand, with a cloth interposing against it, and re- 
tained there until the head is entirely freed from the vulva. 

546. 12th. When the head is in this situation, it should not be 
meddled with ; no effort should be made to withdraw the body of the 
child ; its delivery should be trusted to the subsequent contractions of 
the uterus, that this organ need not be too suddenly emptied, and by 
this means, give rise to flooding. 



Sect. I. — Of the Necessary Duties towards the Child. 

547. Having conducted the labour to the delivery of the child, 
new duties immediately commence; the high importance of which, 
renders it proper we should lay down some rules for their fulfilment. 

548. The first great object after the delivery of the child, is to see 
that respiration is established : for the most part this takes place spon- 
taneously the instant it is in the world ; indeed it very often cries, 
even forcibly, so soon as the head is protruded through the external 
parts. M. Baudelocque has communicated to the Academy of Sci- 
ences, a case of labour, in which the waters being evacuated, the face 
of the child presented to the neck of the uterus, and the child uttered 
cries as strong as if it had been delivered. American Journal of the Me- 
dical Sciences for May, 1831, p. 248. But if it fail to cry soon after 
delivery, attention should be immediately paid, that respiration may 
be established. The child may be born in one of the following con- 
ditions. 1st. Feeble, (but not entirely exhausted,) either by the delay 
in its delivery, by the compression of the cord, or from a delicacy of 



OF THE NECESSARY DUTIES TOWARDS THE CHILD. 161 

stamina. These several conditions may be attended by a pulsating 
cord, or one in which pulsation has ceased. 2dly. The child may 
be born healthy and with the umbilical arteries pulsating strongly. 

549. In cases in which the cord still pulsates, there is but little 
risk, so long as this action continues ; and, for the most part, all that 
is necessary is, to remove all impediments from the mouth of the 
child which may interrupt the passage of air to the lungs ; or by dash- 
ing upon its body some cold spirits or brandy. This almost instantly 
makes it send forth cries, that are most welcome to the accoucheur, 
and are the rewards of the mother's sufferings. But should there be 
no pulsation in the cord, the body flaccid, and especially, if upon di- 
viding the funis, only a drop or two of black blood issues from the 
cut, the case is desperate ; but not always absolutely hopeless. 

550. In this case we should, 1st, carefully remove any mucus that 
may be in the mouth, fauces, or upper part of the trachea, by wiping 
as far as we can reach with the little finger armed with a piece of 
fine dry rag: 2dly, endeavour to inflate the lungs of the child by 
forcing air into them from our own : this must be done by holding 
the nostrils and applying our mouth to that of the child and forcibly 
expiring.* If we succeed in passing air into the child's lungs which 

* M. Velpeau recommends this to be done by means of " a quill barrel" a female 
catheter, or any kind of cannula, introduced into the mouth and nostrils, or by blow 
ing with the mouth directly into the air passages. The laryngeal tube invented by 
Chaussier, bavin? the advantage of pretty exactly filling the glottis when introduced 
into it, is better than the straight cannula of Heroldt; but a simple gum elastic cathe- 
ter, an instrument which can be got any where, is almost as convenient: it is intro- 
duced through the month, as far as the bottom of the pharynx; then while it is passed 
inwards, the point may be bet with the little finger, so as to compel it to enter into 
the larynx rather than the oe-ophao-us ; when fixed right, the nostrils and mouth of 
the fttus are closed, and the inflation commenced. However, if it should be ad- 
mitted that the expe iments tried by Winslow, Heroldt, Schule, Viberg, Schmidt, and 
Beclard, incontestubly prove that the liquor amnii penetrates during intra-utcrine 
life as far as the bronchia, it would be useful to free the trachea fiom it by suction or 
otherwise, previously to trying inflation; but there is too much uncertainty upon this 
point for it to serce as a basis for any practice v^atei-cr^ p. 564. Dr. Meigs's 
translation. 

We rarely meet with an assemblage of directions or suggestions, that contain so 
little of practical usefulness as we do in the above quotations. First, the kind of in- 
strument to be used upon such occ:isi"ns is far from being satisfactory ; for neither the 
quill, nor female catheter, nor any kind of cannula, can be used with any prospect of 
success, unless one of its extremities p.ss into the trachea ; and this requires no com- 
mon adroitness to render its location exact, oi its operation profitable. But if this dif- 
ficulty were surmounted by one of these instruments, we arc every way certain that 
violent irritation must ensue, especially from "the quill or any kind of cannula," and 
thi- we fear without proportional advantage ; for we doubt very much whether the 
lung? can be inflated by these means without the employment of very many more 
precautions than are rf commended by M. Velpeau. Besides, it would be proper 
to put every practitioner, but especially the young, in possession of means that 
can always be commanded, rather than to make him rely upon instruments for this 
common purpose, that can rare y be pocircd ; but nt the loss of so much time 
that would be fatal to the child — for the loss of five minutes upon such occasions, 
most commonly seals its fate. For though the " gum elastic catheter may be got 
any where," (that is, any where in Paris, the child would often lose its life, were it 
required to be sent for out of the house ; and in this country, nay, cv«n in thi3 

15 



162 OF THE NECESSARY DUTIES TOWARDS THE CHILD. 

is easily known by the elevation of the chest; and if the air we have 
thrown in is not immediately returned, we must quickly expel it, by 
a gentle but pretty firm pressure upon the thorax : 3dly, by placing 
the child's mouth downward holding the body and hips higher 
than the head ; at the same time gently shaking the child, so as 
to disengage any mucus that may be lodged in the trachea : and 
permitting it to flow from the mouth, by making this the depending 
part*— then cautiously wiping the mouth as just directed ; renew 

city, much time would be lost, were this instrument to be relied upon. The applica- 
tion of the accoucheur's mouth, to that of the child, as we have just recommended, 
is the only means that can be depended upon for the inflation of the child's lungs. 
Secondly; however M V. may scout the idea of the trachea being at least partially 
filled with the liquor amnii, and disregard the precaution of removing it, we do ad- 
vance upon our own proper experience, that it is an accident by no means of uncom- 
mon occurrence ; and there is no such "uncertainty upon this point," as to render at 
all doubtful the practice necessary up<m such occasions. For we do further aver it 
as our firm opinion and belief, that we have saved the lives of very many children 
by the plan recommended in our text. 

Dr. Patterson, in the " Bridgewater Infirmary Reports," relates two instances of re- 
suscitation by cold water. As these cases are replete with interest, we shall relate them 
as noticed in Med. Chii urg. Rev. for August, 1833, p. 265. 

Case 1 — "Mary O'Brien, of Rathkeale, aged twenty-four, in June, 1831, was seized 
with premature labour of her first child. She stated that she had only reached the 
commencement of the eighth month of gestation, and attributed her impending abor- 
tion to fright. Her pains being slow, after about thirty hours of lingering labour she 
was delivered of a still male infant. Immediately on the protrusion of the fcetus, a 
very languid circulation was perceptible in the funis, and a slight motion of the 
limbs was observed. Previous to the division of the cord, it was attempted to ex- 
cite respiration, but the funicular pulse having quickly ceased, the child was re- 
moved ;ind subjected to artificial inflation, friction, external warmth, and nasal irrita- 
tion. There being no appearance of benefit, and ten minutes having been lost in 
these fruitless attempts, I placed the infant in a tub, and twice dashed over it three 
quarts of water, the temperature of which was about sixty degrees. On the first dash, 
a slight convulsive motion of the body was sensibly excited ; after the second, the 
heart and lungs were in evident actum, but this was exceedingly weak and tremu- 
lous. While the babe was allowed to remain for a few moments in the water, which 
scarcely reached its ears, the thoracic parieties were subjei ted to strong friction. In 
effecting this the integuments were made to glide^ to and fro, over the ribs so as to 
excite titillation. Movements of the arms and legs, and active respiration having 
quickly succeeded, the child was removed from the vessel, well dried, and wrapt up in 
flannel. It slowly acquired strength and activity, but ultimately, became remarkable 
for its large size and healthy appearance." 

In the second case, there was no appearance of life, yet vitality could not have been 
long extinct. The funicular connexion was, therefore, speedily separated, and imme- 
diate recourse had to cold effusion. At first a momentary shuddering was observed, 
and, in the next instant, the heart's action was comparatively vigorous. The child 
recovered, and both are now living. 

* We regret to find the following passage in Velpeau's directions for the treatment 
of children born in a state of asphyxia — " There is no reason to believe that it is either 
safe or useful to turn the child with its face downwards to force the matters contained 
in the trachea to escape therefrom." We say we are sorry to observe the above opi- 
nion so peremptorily announo d ; as the authority of M. Velpeau might lead to the 
neglect of this highly important, and in some instances, this indispensable practice. I 
am every way persuaded, that I have preserved the lives of many children by this 
mode of management, which, without it, would have been lost. And we are altogether 
as certain, that no possible injury can arise from the practice, unless it be from mal- 
adroitne>s in the handling of the child. We «re also persuaded that it is vastly more 
efficacious, and to say the least, as ^afe, as the direction he gives immediately before 
for the same purpose, namely, to cleanse the mouth by a brush either drtj, or dipped in 



OF THE NECESSARY DUTIES TOWARDS THE CHILD. 163 

the inflations, and the suspensions alternately, until the mucus flow 
from the mouth ; by proceeding in this manner, I have often had 
the satisfaction of seeing the child restored, under very discouraging 
circumstances. It is every way worthy of remark, that owing to the 
tenacity of the fluid within the windpipe, we cannot at first force air 
into the lungs ; but, by a little perseverance, we overcome this 
obstacle, and the mucus becomes sometimes so thinned as to flow 
readily from the mouth, and at once relieves the child. This opera- 
tion should never be neglected : nor should it be too soon relin- 
quished ; especially if we can excite a few pulsations in the heart 
and in the cord. Both of these should be carefully examined after 
each inflation : the pulsation of the heart is best detected by placing 
the ear immediately over its region ; that of the cord, by pressing it 
between the thumb and finger, close to the umbilicus. 4th. By the 
frequent application of heated cloths : this should be attended to im- 
mediately, and persevered in until the last moment of hope. In the 
August number of the Lond. Med. and Phys. Jour. w r e find the fol- 
lowing notice of a method to resuscitate still-born children, which, 
from the manner it is announced, seems to be considered as new by 
the editor : at this, we are not a little surprised, as the plan has been 
recommended for many years by us, both in our public and private 
lectures, as well as in the first edition of this work. Many years' 
experience has confirmed the efficacy of the method, though we lay 
no claim to the suggestion. We cannot pretend to say, at this 
moment, from whose recommendation we first employed it ; but we 
are certain, that it has been our method for forty years ; and that we 
firmly believe we obtained it at second hand. But this is of no con- 
sequence. Its almost uniform success renders it valuable ; and, if it 
be not generally known, as would seem to be the case, from the 
position it occupies in a widely circulating and highly useful Jour- 
nal,) it ought to be ; especially as, agreeably to the authority 
about to be quoted, it has succeeded in some apparently hopeless 
cases. 

Mr. J. Toogood, of London, has related some cases in which he 
has recovered infants apparently dead, after an unusual length of time. 
In one case no effort was made to respire for thirty-five minutes ; in 
another, forty-five minutes had elapsed; in a third, thirty minutes; 
and in a fourth, the mother's situation was so critical, that the child 
was not attended to for more than half an hour ; it had been wrapped 
in a cloth and removed to another room. An attempt was immediately 
made, and in twenty-five minutes signs of life were manifested ; and 
in fifteen more, the child breathed freely. Mr. T. has always suc- 
ceeded in resuscitating infants who were iiving during the birth. He 

salt and water, and indubitably more rational and efficient than the one that follows ; 
to wi', " supposing the secundines are either who'ly expelled, or on the point of being 
expelled, and that there should be some pulsation in the cord, I should not object to 
keeping them for some time in warm wine and water ! .'" M. V. has not told us, how- 
ever, how the wine and water is to be applied to the unexpelled secundines. 



164 



OF THE NECESSARY DUTIES TOWARDS THE CHILD. 



puts no confidence in the warm bath, in frictions, nor in pouring 
stimulants, but endeavours to imitate natural respiration, by placing a 
napkin over the mouth, pressing out the air from the chest afterwards. 
When a feeble attempt is made by the child to inspire, the inflation 
should be made quicker; and afterwards a little aq. ammonise or 
brandy, rubbed over the palm of the hand, and held over the mouth 
during the inflation of air, will materially assist the recovery. I much 
prefer dry warmth as an application to the child's body, to the warm 
bath which is so much relied on in such cases: I think the latter de- 
cidedly injurious, though I cannot pretend to explain why.* Might 
not a properly constructed syringe be highly useful in removing the 
obstructing mucus? 

551. When the child shows signs of returning life, it is generally, 
by a deep short sob, which may be repeated at longer or shorter in- 
tervals ; but when we think the interval too long, w<e should renew 
the inflations, &c. Should respiration be but feebly restored, we 
should carefully guard against any thing like fatigue to the child ; it 
should not on any consideration be disturbed by dressing ; on the 
contrary, it must be carefully placed in such a situation, as will permit 
the frequent renewal of the warm applications, w T hich are of primary 
consequence to the well doing of the child. I have had more than 
once the mortification to see all my endeavours frustrated, by inatten- 
tion to my directions upon this point, though given as impressively as 
I well knew how. 

552. 2d. The child may be born healthy and strong, with a brisk 
pulsation in the funis, yet not cry ; because a mechanical obstruction 
from mucus prevents the ingress of air into the lungs. This mucus 
maybe in the mouth or posterior fauces, or it maybe in the trachea' — 
if in the first, w r e may remove it entirely by a piece of fine rag upon 
the little finger, as just suggested ; (550) if in the second, by suspend- 
ing the child, as just directed, w T hich will seldom fail to give relief, 
by permitting the mucus to run from the mouth. I do not recollect 
an instance, where it was necessary to have recourse to inflation if the 
pulsation in the cord continued ; but if it stop before respiration be es- 
tablished, recourse must be had to inflation. When the child is about 
to make attempts to cry, I often enable it to succeed, by dashing its 
body with spirit or brandy, as directed above. 

553. 3d. The child, from being long delayed in the passage, or 
from having its neck tightly begirt with the cord, may be still-born ;f 

* Does the warm bath invite too much blood to the capillaries of the surface, and 
thus deprive the general circulation of a quantity that is essential to the well perfor- 
mance of this process? 

t Very little attention has been paid, until lately, to the pathological condition of 
children who die in a state of asphyxia in corning into the world. It has now attract- 
ed the attention of the French pathologists, and some curious facts have presented 
themselves, especially as regards the state of the liver. Andral says, that "a me- 
chanical cause will sometimes produce a congestive state of the liver during the pro- 
gress of a labour; and in those chidren who die in a state of asphyxia, will cause a 
rupture of the hepatic vessels ; and from excessive engorgement an effusion is found 
on the convex surface beneath the investing membrane of the liver. And Billard has 



OF THE NECESSARY DUTIES TOWARDS THE CHILD. 165 

in this case its face will be black, or livid, and swoln — the arteries 
may have ceased to beat, or they may beat vigorously — in such cases, 
nothing can save the child from immediate death, but the instant ab- 
straction of blood by cutting the cord* should the pulsation have ceased, 
we may sometimes still succeed in drawing some blood by forcing it 
from the cord, and then employing inflations, &c. ; if pulsation con- 
tinue, we must also abstract blood by cutting the cord — the quantity 
to be drawn must be regulated very much by its effects — when respi- 
ration is established, we need draw no more ; but until some signs 
discover themselves of this being about to take place, we may abstract 
pretty freely, as this process most probably is interrupted by the con- 
gestive state of the brain, which can only be removed by pretty ample 
depletion. 

554. When respiration is established, either spontaneously or by 
artificial means, we apply a ligature to the cord, provided pulsation 
has ceased in it; but not until then. The best ligature is a portion 
of a skein of fine thread ; if this be not at hand, a piece of narrow 
tape or flat bobbin will answer perfectly well — it should be applied 
an inch or an inch and a half from the umbilicus, and should be drawn 
sufficiently, to make it securely tight — this precaution is necessary, as 
otherwise bleeding sometimes ensues. We direct the ligature to be 
applied at this distance, lest bleeding should take place, and suffi- 
cient room be not left for a new one between the old one and the 
belly of the child. We once saw a child die from convulsions, owing 
to a want of room for the application of a fresh ligature, where the 
first one had not prevented bleeding, by the second including a por- 

found blood effused into the abdomen, in consequence of this engorged state of the 
organ. 

* Cruveilheir, in his late work, " Anatomic Paihologiquc, &.c." has distinctl} 7 shown, 
that one-third of the children that arc born still in the Maternitc, die from apoplexy. 
A quantity of blood i- found within the cavity of the arachnoid. Most frequently, how- 
ever, it is limited to the surface of the cerebellum ; sometimes it covers the posterior 
lobes of the cerebrum. It rarely occupies the vuitricles; but the author says, ho has 
seen such cases. In all cases, the arachnoid and sub-aruchnoi.i coats of the spinal 
marro » were rilled with blood, so as to distend the dura mater. The cause of this 
apoplectic condition, Mr. C. thinks is inscrut .ble ; he rejects the idea of its being ciused 
by the use of the forceps : indeed, he says these instruments, he thinks, frequently pre- 
vent it. In this, we heartily concur. 

In some cases, there s found a soft tumour of the hairy scalp, which sometimes 
causc< alarm. It is usually situated npon the superior and posterior portion of one of 
the parietal hones, right or left, as t'ic presentation may have been the first or second 
presentation. It is owinnr to an extravasation under the scalp, from the long con- 
tinuance of pains, when the sma lncss of the pelvis <i'her relatively or positively pre- 
vents the fice fro n turning completely into the hollow of the sacrum. It gives the 
sensation to the finger of the bone beintr depressed under that portion of the scalp. It 
requires no particular treatment, as the extravasated fluids will be absorbed in a few 
days. The tumour may be bash' d thr e or four times a day with cold brandy. Some 
have recomnv nded opening these tumours, but our experience is in direct opposition 
to such advice: it rarely takes plice, but with the first child. Professor Ntegle seems 
to think that this kind of tumour is almost always present; hut this is far from liting 
the case : indeed, it newr takes place, but when there is considerable opposition to 
the passage of the child's head. It never takes place in an easy labour. 

15* 



166 OF THE NECESSARY DUTIES TOWARDS THE CHILD. 

tion of the skin of the child within its circle. Madame Boivin directs 
a careful examination of the cord next to the umbilicus of the child., 
as it sometimes happens, that an umbilical hernia exists, and the pro- 
truded portion of the gut may be included in the embrace of the liga- 
ture; she mentions that death was caused in two instances by this 
cause in the Maternite Hospital. In one of the instances, a portion 
of intestine was included, in the other, a part of the little lobe of the 
liver. We are aware, that it is considered a work of supererogation 
to apply a ligature to the cord, by some: but this precaution, in our 
opinion, should never be neglected ; for it is not true, as the advo- 
cates for this carelessness declare, that " after the child has breathed, 
and respiration is well established, the circulation in the umbilical 
arteries never returns," for we have repeatedly witnessed the con- 
trary. We have witnessed several nearly fatal instances of hemor- 
rhagy from the umbilicus, where it has been thought that the vessels 
had been properly protected against this accident. And we find the 
following interesting case related by Mr. Waller, in the London 
Medical and Physical Journal for February, 1829, Vol. Ixi. No. 360. 
New Series, Vol. i. No. 32, p. 121. 

555. " In one instance there was repeated hemorrhage from the 
umbilical cord, which so weakened the infant that it died in a few 
days. This, I apprehended, must have arisen from disease of the 
arteries, as there was no less than six ligatures applied, and by three 
different persons, (myself among the rest,) notwithstanding which, 
how r ever, the bleeding recurred at intervals, and the blood was ob- 
served to issue not from the part at which the ligature was applied, 
but from the extremity of the funis." Is this not an instance of a 
constitutional disposition to hemorrhage rather than one of diseased 
arteries ? The cord should be cut by a pair of scissors,* half an inch 

* Formerly many prejudices existed on the subject of cutting the navel; and even 
the instrument with which this should be performed. Alphonse Le Roy is, however, 
the only modern I know, who seriously recommends attention to this point. He directs, 
that " we should not cut the cord, but when the pulsation in the cord has nearly ceased." 
And adds, that, "as regards the moderns, respecting 1 the cutting of the cord, all is ne- 
gligence or want of care. But among the ancients, it was an act that had its rules, 
nay even laws; and among certain people, even now, much precaution is exercised. 

That "the ancients never employed instruments made of iron to cut the umbilical 
cord; for," adds he, gravely, "it is very dangerous, in this operation, to do so within 
the tropics. For if we apply a microscope to the cut portion of the cord, we shall find 
particles of the metal oxydized, or ni>ted; and these are more numerous between the 
tropics, ihan in other climates. These particles exert a deleterious effect upon the 
wounded cord, which, in hot climates, is destructive to the whole economy of the 
child." 

" It was," continues he, " with a view to avoid these dangers, that Moses ordered 
circumcision to be performed with a sharp-edged stone. And the Jews in all eoun. 
tries, without understanding the reason which governed their lawgiver, abide with 
great exactness to his precepts, and never employ instruments made of iron or steel."— 
Medicine Maternelle, pp. 6 and 7. 

It would be nowise difficult to perceive too much refined speculation in these opinions ; 
and not at all difficult to account for Moses employing for this purpose a stone instead 
of iron ; and aa easy to prove, that in this and many countries, a well-tempered knife, 
is employed for the purpose of circumcision, instead of a rough-edged stone. We have 
frequently seen this operation performed, and it has always been with a knife of steel. 



THE UNASSISTED DELIVERY OF THE PLACENTA. 167 

at least beyond the ligature — it is never necessary to place two liga- 
tures, except there be twins — or the cord very large. In this case, 
Mariceau advises the application of two ligatures, as the cord shrinks 
from the knot, and thus causes a bleeding ; which occasionally causes 
death — indeed, it is best not to do so:* as the evacuation from the 
open extremity of the cord will yield two or three ounces of blood 
sometimes, which favours the contraction of the uterus, and the ex- 
pulsion of the placenta — it favours the contraction of the uterus, by 
the vessels of the placenta emptying themselves, and thereby di- 
minishing its bulk; this reduction proves a general and grateful sti- 
mulus to the uterus, and promotes its contraction ; this contraction 
acts upon the placenta, so as to disengage it from its surface, that it 
may be expelled soon after the child is born. 



Sect. II. — The Unassisted Delivery of the Placenta. 

556. After the child is separated from the mother, it is to be given 
to the nurse, and removed from the bed-side — the next duty is to 
deliver the placenta — but before this is attempted, we should first 
ascertain the condition of the uterus, by examining it through the pa- 
rietes of the abdomen, by placing a hand over its region. This exa- 
mination will discover this organ in one of two conditions: namely, 
contracted, or not contracted. If the first, the placenta may be de- 
livered, provided it be loose in the vagina, by tightening the cord 
with the left hand, and tracing it with the fore-finger, of the right 
to the placenta, which is to be hooked with the introduced finger, 
and gently drawn by the cord with the other hand, until it pass 
through the os externum — we should then grasp it with both hands, 
and r^ive it several twirls, to twist the membranes, that they may be 
entirely withdrawn from the uterus — the advantages of this proceed- 
ing are, we prevent a terrible stench ; and occasionally, alarm ; for 
we have known them, when about to escape from the vagina some 
days after delivery, to excite great terror in the patient and her 
friends; by their being mistaken for a falling down of the uterus. 

557. When the placenta is delivered, it is to be carefully placed 
in a basin, or pot, and removed— the abdomen should again be ex- 
amined ; should the uterus be well contracted, which is easily de- 
termined by its hardness and size, we should entertain every reason- 
able hope, that every thing is going on so far well ; but should the 

Nor is it reasonable to suppose that Moses could have been aware of oxydizcd particles 
being- left by the knife, even if it were a fact; as the microscope is necessary to their 
detection. 

* " No harm can possibly arise from the application of two ligatures, and wc con- 
sider it the safer practice." (Lond. Med. and Phys. Journ. Aug. p. 145.) 

I regret that the gentleman who honoured this work with his notice, did not state 
why two ligitures were safer than one. An experience of more than forty years, has 
not furnished me with an instance, in which inconvenience has resulted where only 
one has been applied. 



168 OF PUTTING TO BED. 

uterus be found flaccid, brisk frictions with the open hand, with the 
occasional grasping pressure of the fingers, should be instantly made. 
Should these be successful, the uterus will be found to harden gra- 
dually, as well as to diminish in size under the hand. At this mo- 
ment, perhaps, there may be a sudden discharge of coagula from the 
vagina, accompanied by some pain, which very frequently alarms the 
inexperienced practitioner, and renders him doubtful of the propriety 
of the plan he is pursuing ; but so far from being alarmed at this cir- 
cumstance, he should felicitate himself upon it ; as it is a proof that 
the uterus is contracting. These frictions should, however, be con- 
tinued for some time ; or until the uterus becomes very hard, and ap- 
pears to be disposed to retire within the pelvic cavity. 



Sect. III.— Of Putting to Bed. 

558. As the patient is usually delivered at a part of the bed distant 
from where she is to be permanently placed, the removal from one 
to the other is familiarly called " putting the patient to bed." This 
operation consists of several details, w T hich are highly important to 
be well understood by the young practitioner ; though the executive 
part does not strictly belong to him. " Putting to bed" consists, 
first in the entire removal of all the wet things that may be about the 
woman, and substituting dry ones ; secondly, in her being lifted or 
slid into the place where she is permanently to lie ; thirdly, in the 
application of a bandage over the abdomen, pinned as tightly as the 
patient can bear with comfort. 

559. It may be asked, is every woman to be put to bed so soon 
as she may be delivered ? certainly not : the " putting to bed," 
must be governed by the following circumstances : first, if the patient 
be very much exhausted by the severity of labour, by a previous 
flooding, or any other circumstance that may render her feeble or 
faint, she must not be removed until she recover some of her spent 
strength, should this require even several hours; secondly, should 
the patient, from her exertions during labour, or the heat of the 
weather, be in a perspiration, she should not be disturbed until this 
has gone off entirely ; thirdly, should there be too great a discharge 
or flooding, the patient must not be moved, until this is much di- 
minished or stopped. But if neither of these conditions present 
themselves, it is best to direct the patient tb be put to bed immedi- 
ately, as I am persuaded she will bear it better than if suffered to re- 
main any time. 



Sect. IV. — Of After-pains. 

560. Almost every woman, with the exception, perhaps, of the 
first child, is tormented with what are called " after-pains," these 



OF AFTER-PAINS. 169 

pains are produced by the renewal of the alternate contractions 
of the uterus in consequence of coagula forming from time to time 
within its cavity, and now being foreign bodies, efforts are made by 
the uterus to expel them. These coagula are formed by the blood 
flowing into the cavity of the uterus from the extremities of the ves- 
sels exposed by the separation of the placenta — and they will form 
in proportion as the uterus may be more or less disposed to contract ; 
therefore, it is found, that the more this organ is closed by virtue of 
its tonic power, the fewer and milder will be the "after-pains:" 
hence these pains rarely occur with the first child, as the tonic power 
of the uterus is then more perfect, or less exhausted. There is a cir- 
cumstance attending these pains which deserves notice, though it 
may not be easily explained; which is, there almost uniform renewal, 
upon the application of the child to the breast, though they may have 
been suspended even for hours; and the aggravation of them, if they 
have not been interrupted. 

561. These pains, by the old women, are considered useful, be- 
cause they are almost always accompanied by the discharge of coa- 
gula, which they say must come away, and on this account they 
oftentimes refuse to give any thing for their relief. But this doctrine, 
were it strictly acted upon, would subject the patient to most unne- 
cessary tortures, sometimes for many days together — I have ever re- 
garded after-pains as an evil of magnitude, and always endeavoured 
to prevent them as quickly as possible — they interrupt sleep, which 
is at this time of especial importance to the exhausted woman, as 
well as needlessly excruciate the body. 

562. I generally prescribe camphor for their relief and in the fol- 
lowing: form : 



•& 



R. Gum. Camph. £j. 

Sr. vin. rect. q. s. f. pulv. — Adde 
Pulv. G. Arab. 5ij. 

Sacch. alb. Jij. 

Aq. font. §vj.— M. 

Of this a table spoonful is given every hour or two, or oftener, until 
the pains cease — or, I sometimes give ten grains of this substance 
finely powdered, every hour or two, mixed in a little sirup of any 
kind: this appears to answer nearly as well as the julep just men- 
tioned. 

56-3. The camphor in two or three instances, has disagreed with 
the patient though it relieved the pain. In these cases, it produced 
most distressing feelings: as headach and delirium ; but they soon 
disappeared upon desisting from it* — it has a decided advantage over 

• In one case the unpleasant symptoms were so excessive, as to oblige me to give 
an emetic of ipecacuanha. As soon as the camphor was thrown up, the patient was 



170 OF AFTER-PAINS. 

opium ; for in many instances it can be given where the opium is 
altogether improper, either from the state of the pulse, or idiosyncrasy ; 
besides, it more certainly gives relief. I think, however, that the re- 
lief is not quite so permanent as that procured by opium ; and there- 
fore, we are sometimes obliged to repeat it more frequently. Should 
the camphor fail to give relief, or constitutional peculiarity render 
it improper, we must give the opium ; provided, there be no circum- 
stance of the system, as fever which would make it inadmissible. I 
have in a few instances been obliged to let blood, from the high ac- 
tion of the arterial system, before I could venture upon the use of 
opium ; but these cases are rare, though of high consequence to be 
well understood in practice ; I have, however, given the camphor, 
where I dared not venture upon the opium ; and this is important to 
know, as preparatory bleeding always excites alarm. 

564. We often find patients who cannot use opium in any of its 
common forms, in consequence of its disagreeable after-effects ; such 
as severe headach, and distressing sickness of stomach.* But these 
consequences may very often be prevented by mixing the laudanum 
with vinegar instead of water : or using the acetated tincture of opium, 
or black drop. When used, it should be in such doses as will 
quickly make an impression upon the system — I, therefore, always 
begin with a dose of fifty or sixty drops, and repeat it every half hour 
or hour until relief is procured ; if the black drop be made choice of, 
it should be given in half the quantities of the laudanum. If this 
plan be persisted in for a short time, it will certainly relieve the 
patient.f 

565. I have met with a few cases of a very distressing kind of after- 
pain, which I have not seen noticed by writers. It is a most severe 
and constant pain at the very extremity of the sacrum and coccyx ; 
it begins the instant the child is born ; and continues with the most 
agonizing severity, until overcome by the rapid and liberal use of 
camphor and opium. It is declared by the patient, to be vastly more 
insupportable than the pains of labour : for it is as intense as un- 
ceasing. 

566. The first case of this kind I met with, occasioned me no little 
anxiety and perplexity, from its novelty and severity. It was the 
case of a young lady w 7 ith her first child — it began most severely, the 
instant the child was born ; and its intensity was such as to make me 

relieved. But these are extremely rare cases : and were I to institute a comparison, I 
would say, that opium disagrees five times as often as camphor. 

* Dr. Hare has pointed out a method of freeing opium from its narcotine ; and lau- 
danum is now prepared from the residue, with the great advantage of not producing 
any, or but in a very slight degree, the distressing effects of that made in the common 
way. We regard this among the happiest and most important discoveries of modern 
chemistry. 

t Until the " denarcotized laudanum" gets into general use, as it certainly will, the 
plan recommended in the text may be pursued with advantage. The late Dr. Physick 
informed me, that he was in the habit of using a few grains of the carbonate of soda 
or potash, with the same good effects. 



OF AFTER-PAINS. 171 

abandon the delivery of the after-birth, to attempt the relief of my 
patient. I at first looked upon it as only a protracted after-pain, 
which I had not expected to encounter with a first child. I immedi- 
ately gave a large dose of laudanum, and repeated it in fifteen mi- 
nutes—at the end of the second quarter of an hour, as there was no 
abatement of the suffering, I again gave the laudanum — these doses 
procured no relief, in half an hour more ; though, in the three portions 
exhibited, more than two hundred drops of this medicine were given 
in the course of half an hour. I was obliged now to suspend the re- 
petition of the laudanum from a fear of an excess in its exhibition; 
but, to amuse the patient, I gave her a few drops at a time, disguised 
by a little of the compound spirit of lavender, until an hour had 
passed. By this time the patient thought herself easier ; but still suf- 
fered very severely — I now ventured upon another full dose of lauda- 
num, and sat down to deliver the placenta : this was readily done, and 
it was found lying loose in the vagina ; but its expulsion procured no 
abatement of suffering — in a word, nearly five hundred drops of lau- 
danum were admininistered, before complete relief was obtained. 
After she became easy, she had no subsequent return of this pain ; 
nor did she suffer in the least, from the use of so large a quantity of 
laudanum, in so short a period. 

567. On the termination of her next labour, as she had most anx- 
iously and fearfully anticipated, the same violent distress assailed her. 
I instantly gave her, at one dose, one hundred and twenty drops of 
laudanum ; this was repeated in twenty minutes — in the mean time, 
the placenta was spontaneously discharged. This second dose af- 
forded no relief; and I was then induced to administer the laudanum 
at short intervals, which, as before, eventually overcame the pain — as 
happened on the former occasion, she suffered no return of this pain 
after it had once been subdued. 

56S. On her third confinement, I was again distressed to find a re- 
currence of this terrible agony. I had, however, from my former ex- 
perience in her case, anticipated this event, and had at hand the fol- 
lowing julep: 

R. Gum Camph. 5n\ 

Sp. vin. rect. q. s. f. pulv. — Adde 



Pulv. G. Arab. 


3iii. 


Tinct. opii acetat. 


Jiiss. 


01. Juniperi. 


gut. xx. 


Sacch. alb. 


q. 8. 


Aq. font. 


3vi.-M 



Of this, a large table-spoonful was given about fifteen minutes before 
I expected the child to be born, by way of making some impression 
before the pain should come on. The child was born rather within 
the period I had calculated ; and, as on the two former occasions, the 
pain commenced the instant it was in the world ; another spoonful of 



172 OF AFTER-PAINS. 

the julep was immediately given, and this was followed by another in 
fifteen minutes more, which decidedly abated the severity of the pain ; 
and I had the satisfaction of seeing it entirely conquered, in an hour 
from its commencement ; a period less by one half than on the former 
occasions. The placenta came away without trouble, as it had always 
done before. I thought it evident, that the combination of camphor 
with the opium was highly beneficial ; and, perhaps, they were aided 
by the oil of juniper, which I had frequently found very useful in con- 
trolling after-pains. On her fourth delivery she was managed pre- 
cisely as above related, and with the same happy effects.* 

569. The second and third cases which fell under my notice, were 
treated with camphor julep, as above stated, and with the same happy 
results. Can this pain be considered as a modification of after-pains ? 
I am disposed to think not ; as its commencement is too sudden, and 
its duratjon too uninterrupted ; besides after this pain has ceased, the 
part no longer becomes the seat of pain, should after-pains follow. 
That strange variations in the seat of after-pains occasionally take 
place, I have witnessed ; but in all the aberrations I have observed, 
the change of seat did not alter the character of the pains (neuralgic) 
for they were all of the alternate kind, and as regular as if they were 
seated in the uterus. One of the most remarkable I remember to 
have met with, was where the after-pains were located in the right 
knee ; and this peculiarity in seat obtained with every child this lady 
bore.f 

570. I am of opinion, however, that much may be done before the 
labour is finished and immediately after, to abate the severity, if not 
to prevent the occurrence of " after pains." During labour, 1st. By 
rupturing the membranes whenever the mouth of the uterus is suffici- 
ently dilated to permit the head to pass, that the tonic contraction 
may immediately ensue. By this the following advantages result as 
regards the prevention of " after pains :" by the absence of the waters, 
the uterus is reduced in size, in proportion to the quantity discharged ; 
this gives greater strength to this organ, and enables it to contract 
with more force, and consequently, will more certainly diminish the 
size of the vessels exposed by the separation of the placenta ; as they, 
by pouring out blood, give rise to these " after pains ;" (193) again, 
it prevents the uterus ftom being too suddenly emptied ; and thus in- 
ducing a state of atony in it — for it must be remembered, that " after 
pains" are nevermore certain, nor ever more severe, than after a very 
quick labour. 2d. By permitting the uterus to finish the labour after 
the head is born ; in doing this, we have an assurance that the tonic 
contraction has regularly followed ; as the uterus becomes more and 

* This lady suffered in the same manner with her fifth and sixth children. 

+ Dr. Bird* mentions neuralgic pains of the abdomen stimulating pueperal fever af- 
ter delivery. We have seen many such cases ; but they have always been relieved by 
treating them as a variety of after-pains. 

* Amcr. Journ. of Med. Scien. for August 1S40. 



OF AFTER-PAINS. 173 

more empty ; for, were this not the case, the alternate contractions 
would be feeble and transitory, as always happens, when the 
shoulders are about to be hurried through the external parts and the 
uterus too suddenly emptied ; in this case the tonic contraction of 
course is imperfect — consequently, the vessels exposed by the sepa- 
ration, and departure of the placenta, are not pressed upon by this 
power ; and consequently blood is freely poured into the cavity of 
the uterus, where it coagulates, and obliges the uterus to throw it off 
by repeated contractions. 3d. After the delivery of the child, we 
may do much by not attempting the delivery of the placenta until we 
have ensured the tonic contraction of the uterus, by frictions, as before 
recommended, over the hypogastric region; and after its expulsion to 
repeat them, until the uterus seems to retire considerably within the 
pelvic cavity. Burton's success, (though I should be but little dis- 
posed to follow his practice,) in preventing " after pains" by the 
introduction of his hand to the fundus of the uterus, and kept there 
until he found this organ contracting upon it, depended precisely 
upon the principle I have been endeavouring to establish ; namely, 
promoting as quickly and as certainly as possible the tonic contrac- 
tion of the uterus. 

571. It must, however, be admitted, that neither camphor nor 
opium is always successful in calming these distressing contractions 
of the uterus ; they sometimes persevere with great obstinacy, even 
after the faithful trial of both these remedies; while in other cases no 
form of opium can be made to suit the peculiar idiosyncrasy of the 
patient, and to some the camphor is altogether disgusting. In such 
cases it may be highly useful to exhibit the hydrocyanic acid, as re- 
commended by Dr. Von dem Busch, of Bremen. 

572. As this is a new remedy in spasms of the uterus, and as its 
effects were highly satisfactory to Dr. Von dem Busch, I will subjoin 
the two cases related by him in Hufeland's Journal for September, 
1826. 

573. Case I. " Madame N., aged thirty-three years, was safely 
delivered in the morning of the 14th of May, 1821. A short time, 
however, after she was put to bed, she was attacked with a violent 
vomiting, and severe after-pains. She was visited an hour after by 
her physician ; she had by this time vomited five times, a green, 
bitter substance like bile ; the pulse was full and hard ; the abdomen 
tense, and tender to the touch ; the skin hot, but the face not flushed ; 
tongue clean, and thirst great. The patient complained of pains in the 
uterus ; and when they became very violent, they excited nausea and 
vomiting. The lochia was very sparing. Three drops of the hydro- 
cyanic acid, mixed in an ounce and a half of sirup, was given by tea*- 
spoonsful every hour. In the evening the pulse had softened, the 
patient had vomited but twice ; the abdomen still painful to the touch ; 
nausea continued, but the after-pains were much less frequent. The 
lochia returned in abundance during the night of the 14th, and the 
day of the 15th, after having repeated during the day the mixture > 

16 



174 THE REGIMEN DURING THE MONTH, &C. 

it was now given but once in three hours, as the pains had entirely 
disappeared. This lady has been twice delivered since ; in both she 
again suffered with after-pains, but not accompanied by vomiting; in 
both cases she was relieved by the same remedy. 

574. Case II. " Madame S., a well made robust woman, twenty- 
eight years of age, was always delivered safely, and without any thing 
unpleasant following her labours. But in her fourth delivery, the 
after-pains were so violent as to cause convulsions. The lochia were 
nearly suppressed; the pulse full and hard ; the tongue clean, and 
the skin hot ; pressure on the hypogastrium increased the pain. Four 
drops of the hydrocyanic acid in two ounces of sirup were ordered ; 
of this a tea-spoonful was given every hour and a half. The pains 
subsided presently, and by the time the mixture was finished they had 
ceased entirely ; in the mean time the lochia returned to their healthy 
condition." Revue Medicale, &c, for April, 1827. 



Sect. V. — The Regimen During the Month, fyc. 

575. There is no vulgar error more replete with mischief, than that 
which supposes the woman to be in a state of great debility after de- 
livery, and to require the most nourishing, and the most stimulating, 
things to overcome it — hence the destructive use of ardent spirits, 
wine, cordials, spices, animal food, broths, &c, &c, during the whole 
period of confinement. We cannot too decidedly set our faces against 
such practices ; and with a hope of preventing them, we should give 
to the nurse the most explicit directions, as well as the most positive 
injunctions, with regard to the regimen of the patient, before we leave 
the room ; and we should see, as far as may be in our power, that our 
instructions are carried rigidly into execution. 

576. Should we have reason to suspect, or have positive evidence 
that they have been departed from, we should at once, without regard 
to the nurse's experience or respectability, tax her with this disobe- 
dience — for it must be recollected that the whole responsibility lies with 
the physician ; and if he do not support his instructions with proper firm- 
ness and dignity, and see them correctly acted upon ; if he pass in 
silence the improper conduct of the nurse he will constantly and ever- 
more have his directions infringed, and his skill and experience, be 
they what they may, rendered nugatory. 

577. But to return to the regimen proper in the month ; I desire that 
the patient may not have animal food, or broth from any animal sub- 
stance ; that she may take neither distilled nor fermented liquor ; nor any 
stimulating tea " to dispel wind," or " to allay after-pains," or " to pro- 
mote the lochia." I direct she should have gruel of oat meal, tapioca, 
sago, panada, mush and milk, rice and milk, tea, coffee, or very thin cho- 
colate. Ipermitto be seasoned with sugar, a little nutmeg, or lemonjuice, 
any of the articles above enumerated, in which it would be proper to use 
them. I permit the use of toast- water, barely- water, mollasses and water, 



THE REGIMEN DURING THE MONTH, &C. 175 

or balm-tea as common drinks ; or, what is very often extremely grateful 
to them, apple-water — that is, a roasted apple or more, well beaten 
with water, and afterwards, strained. This diet is to be observed 
strictly until after the fifth day ; or until the milk has been freely se- 
creted, and is easily extracted — after this time, all things being right, 
she may be allowed the soft ends of four or five oysters, or a poached 
egg, a little chicken-water, beef-tea, or vegetable soup may follow, 
until about the tenth day: then, (nothing forbidding,) she may indulge 
in a little ale, or porter and water at her dinner ; and if requested, a 
table- spoonful of white wine may be added to the gruel, &c. This 
plan I persevere in until after the fifteenth day ; at which time she 
generally may take some animal substance, such as broiled or boiled 
chickens; birds of almost any kind; a piece of beef-steak, mutton- 
chop, <x.c. 

57$. The child should be put to the breast, as soon as the mother 
is well-rested from the fatigue of labour: this is an important direc- 
tion ; and should not, without very strong reasons, be neglected : the 
advantages of this early application of the child to the breast, are, first, 
the child keeps the faculty, (if we may so term it,) of sucking, with 
which it is born ; for if this direction be not attended to for several 
days, because, as they say, the mother has no milk, it will lose this 
faculty, and much trouble will be given to recall it — I have witnessed 
this consequence but too often ; secondly, the child's mouth will, by 
its gentle action upon the nipple, gradually stretch it, and accustom 
it to extension, before the breast becomes tender, and swelled with 
milk; thirdly, by the nipple being stimulated by the child's sucking, 
an earlier secretion of milk takes place ; fourthly, the milk will be 
drawn ofT nearly as fast as formed ; which will prevent the pain so 
constantly arising from its accumulation, as well as the swelling, which 
is almost sure to follow its formation. This swelling, if it take place, 
shortens the nipple, and renders the extraction of the milk more diffi- 
cult ; this increases the efforts of the child, by which means the ex- 
ternal covering of this important little organ becomes irritated, and 
sore, to the great misery of the mother, and serious injury to the child ; 
fifthly, the early secreted milk possesses a purgative quality, by which 
the infant profits, by its assisting in carrying off the meconium. We 
are persuaded, that the " milk fever," as it is called, is nearly alto- 
gether of artificial origin, and can almost constantly be prevented. We 
have been always attentive to this subject, and an ample experience 
leads us irresistibly to this conclusion. In a practice of more than 
forty-five years, we have witnessed but two instances of inevitable 
"milk fever." In both of these, every pains were taken to prevent 
the formation of this fever ; but in neither did a severe antiphloj 
treatment prevent it — in both of these cases, the patients were ex- 
tremely prone to fever from very slight causes. We, therefore, cannot 
agree with Professor Dubois, that the " milk fever " is a legitimate 



176 THE REGIMEN BURING THE MONTH, &C. 

traumatic fever occasioned by the separation of the placenta from the 
uterus.* 

579. It should be directed, that the room be constantly ventilated ; 
the curtains, if there be any, should always be open ; and where we 
can command, we should forbid them altogether, in warm weather. 
They should never be drawn because the woman sleeps, or with a 
view to protect her from a draught of air ; for the woman can sleep 
without closed curtains; and can by other contrivances be protected 
against a current of air, She should have a plentiful change of clothes, 
that the lochia may not become offensive; and after the third day, she 
should be permitted to wash the parts with w T arm water, two or three 
times a day — this last permission is a great comfort to a delicate wo- 
man ; and should not, under frivolous pretences, be denied her. 

580. On the third day, if the bowels have not been previously 
opened, the woman should take some mild purgative ; castor oil is 
the best; but where this is disgusting, or should disagree, the cal- 
cined magnesia, the sirup of rhubarb, or a little senna tea, will answer 
extremely well. Should the u after pains" be very obstinate and not 
yield to the common remedies, the castor oil will be found to be the 
most useful purgative ; and has this very decided advantage over every 
other, perhaps, that, in cases of great pain, laudanum can be admi- 
nistered, if it be judged proper to exhibit it, without interrupting the 
operation of the oil, though it may retard it a little. A strict atten- 
tion should always be- paid to the state of the bladder — we should 
aever forget to inquire whether the patient has passed' water ; if she 
has not, we should immediately order such remedies as are best cal- 
culated to remove the difficulty — the most certain is sp. nitri. dul. (sp. 
ether, nit.) in tea-spoonful doses, repeated every two hours, until re- 
lief be obtained ; for, if this fail, it is more than probable no other 
diuretic will succeed ; we are then under the necessity of employing 
the catheter: nor should we delay its employment too long. I have 
seen much misery, and perhaps danger, in permitting the bladder to 
be too long distended. 

581. The following is. the mode of using this instrument — the pa- 
tient must be placed at the side of the bed ; the bed should be pro- 
tected by a folded blanket being placed under her. The finger should 
be lubricated with a little sweet oil or lard, and the hand introduced 
under the bed clothes, so as not to occasion the smallest exposure — 
the patient's knees must be drawn up, and the labia separated by the 
points of the fingers— search for the inferior edge of the symphysis 
pubis under which the urethra immediately runs — press this part 
gently with the point of the finger, and the meatus urinarius will be 
for the most part, readily discovered — when found, keep the extremity 
of the finger upon it ; then, with the> other hand, guide the catheter 

* In the Baltimore. Medical and Surgical' Journal, Vol, 2d, page 497, there is an 
account, with a drawing, of a female who had three distinct mammas differing in no- 
thing from each other, either in appearance or in functions, except that the supernu- 
merary mamma is one-third. smaller than the two natural breasts. 



OF THE LOCHIA. 177 

along it until it reach the orifice, and is inserted into it ; press it 
gently backwards and upwards until it enter the bladder ; and pre- 
vent the immediate issue of urine, by placing a finger upon its exter- 
nal extremity until the vessel is handed, which is intended to receive 
it — this is to be so placed, as to prevent the escape of the urine upon 
the bed — when all the water is discharged the instrument must be 
withdrawn. This operation must be repeated until the bladder re- 
gains its powers, and is capable of discharging its contents — it some- 
times becomes necessary to do this twice or thrice a day ; but in 
general once will do.* 



Sect. VI. — Of the Lochia. 

582. The discharges which take place from the uterus after deli- 
very, are called the "lochia" — they proceed from the extremities of 
the vessels exposed by the separation of the placenta ; and wdll of 
course be in proportion to the extent of surface this mass may have 
occupied in the uterus ; the number and size of the vessels concerned ; 
and the degree of contraction the uterus may exert. Should the tonic 
contraction of the uterus be imperfectly performed, a hemorrhage will 
be the consequence, but when more perfectly contracted, the discharge 
will not amount to a flooding, but would yield the lochia. Much con- 
sequence is attached to these discharges ; the good old gossips of 
almost every country are of opinion that the freer they are produced, 
the better; and are always better pleased witb a super-abundant, than 
with a sparing quantity — it is proper, therefore, before we proceed 
farther, that we determine the real nature of this evacuation. 

583. As the uterus never contracts with so much force immediately 
after delivery, as to stop the mouths of all the exposed vessels, a 
quantity of blood must necessarily proceed from the extremities of 
such as are open ; and this quantity will be in proportion to their 
capacities, though perhaps these vessels are now much reduced in 

* i: If it were our only purpose, in such cases to- prevent the woman from suffering 
pain from the snppre-sion of urine, it is true that the use of the catheter once a day 
'will generally do.' But we have a much more important object in view, — to prevent 
the Datura] powt r of the bladder from being- so far weakened by over distention, that a 
very considerable time may elapse before the patient is able to pass her urine. We 
have known the use of the catheter necessary for many weeks, in consequence of the 
contractile power of the bladder having been lost, from the water not having at first 
been drawn off more lhan once in twcntv-foiir hours. We differ then from our author, 
upon this po nt. The introduction of the catheter once a day, ought never to be con- 
sidered -".fficient." — {Ijond. Med. and I'fn/s. Jburn. Aug. 1825, p. 148.) 

The reviewer siys that he anH I differ upon the subject of the catheter — but wc cer- 
tainly do not: on the contrary, we perfectly agree. My practice ever has been, to 
draw off the urine, whenever distention was evi cnt; did this require three or even 
four in 'reductions of the catheter, in twenty-four hours. But more cases have oc- 
currcd, where ome a day was sufficient, than where a more frequent use of the cathe- 
: nor have we ever witnessed a esc, which required a continuance 
of this operation beyond a week. In Europe, this necessity is both more frequent, and 
much more urgent; owing to the much greater frequency of contracted pelves, or te- 
dious labours. 

16* 



2.78 LOCHIA, EXCESSIVE. 

size ; while, on the other hand, the quantity discharged, "will be coe~ 
stantly diminishing in the. exact ratio of reduction, it must therefore 
follow, there is no definite quantity to be evacuated, but will entirely 
depend upon the contingency of the more or less perfect condition of 
the tonic power of the uterus. This being true, it must also 
follow, that the quantity discharged will differ in each individual, 
and in the same individual at each particular labour; conse- 
quently there can be no rule upon the subject. The absolute 
use of this evacuation appears to be, to give the uterine vessels an 
opportunity to contract, by gradually relieving themselves of the en- 
gorgement to which they have long been subject from pregnancy, by 
pouring apart of their contents into the cavity of the uterus; and, that, 
so soon as this engorgement is relieved, all the purposes of the eva- 
cuation are answered ; for the extremities of the vessels, which open 
into the cavity of the uterus, cannot return the blood they contain into 
the circulation, as their anastomoses are destroyed, by their termina- 
tions being opened; they therefore part with it, and thus form the 
lochia; and they will do this, until the tonic contraction is so perfect 
as to shut up their exposed extremities — therefore, as a discharge, 
this evacuation is of no farther use., than to relieve the vessels of the 
uterus, and thus indirectly promote its contraction— it may, however, 
injure by its excess, because it may produce weakness; but cannot 
injure by its scantiness,, when that is the effect of contraction, since 
this is an evidence of the most healthy condition of the uterus. 



a, — Lochia j .Excessive. 

584. As this discharge sometimes injures by its excess, and as that 
excess must necessarily result from a want of due contraction in the 
uterus, it follows as a consequence, that we "always render an im- 
portant service, when we can. increase the tonic powers of the uterus, 
and thereby diminish the quantity of the lochia. I have for many 
years acted upon this principle, and have great reason to be satisfied 
with it. It is very unusual in my practice, to see the lochia too 
abundant; on the contrary, very little of this discharge is to be seen 
after the fifth day, and sometimes it is over sooner. I do not, how- 
ever, say, that, in the cases just alluded to, there is an entire stoppage 
of the discharge ; but that there is a very great abatement of it, both 
as regards quantity and intensity of colour. 

585. The lochia, however, from various causes, will continue for 
a great length of time, nay, during the month, or even longer, to the 
injury of the patient; in such cases, T have made it a rule, to interfere 
whenever it has continued with any force beyond the tenth day. I 
have found this discharge sometimes kept up by a febrile condition 
of the system, occasioned perhaps by an improper consideration of 
the case by the friends of the patient, who could not imagine that any 
other cause than debility produced the discharge in question ; ac- 



LOCHIA, EXCESSIVE. 179 

cordingly, wine, bark, and cordials, were given, with a view to arrest 
it, and thus perpetuated the evil they intended to cure. In such 
cases there are pretty regular febrile paroxysms, especially towards 
evening; a quick full pulse, with considerable heat of skin — the 
tongue furred, the bowels oftentimes much confined ; a feeble state 
of stomach, or a whimsical appetite ; the sleep disturbed and unre- 
freshing; pain in the back, and an occasional discharge of coagula. 
In treating this case we shall have much prejudice to overcome — for 
that fatal term " debility" which has slain its thousands, and its tens 
of thousands, is always employed against us ; " the patient is so weak, 
she wants something to strengthen her," is the unceasing cry of friends 
upon such occasions : and, though they will reluctantly submit to your 
directions, they will rarely coincide with you as to their propriety. 
We must not, however, give up principles, to satisfy the crude 
notions of friends, upon a point so important to the welfare of the 
patient; we must prescribe agreeably to the opinion we have formed 
of the nature of the case, after a due consideration of the symptoms, 
and condition of the vascular system. 

5S6. In cases like these, we cannot expect to abate the discharge, 
until we shall have subdued the febrile condition of the system ; we 
are, therefore, to begin by taking a few ounces of blood, and opening 
the bowels freely, with any of the neutral salts either alone or com- 
bined with magnesia ; by confining the patient strictly to a vegetable 
or mild diet, and the entire proscription of wine or any other liquor, 
and all stimulating teas, such as chamomile, centuary, or mint. By 
forbidding all exercise, or even sitting up in severe cases; by placing 
the patient upon a mattress, instead of a featherbed ; by ordering the 
parts to be bathed with cool water, three or four times a day. After 
having bled and purged as just suggested v we may give from a grain 
and a half to two grains of the acetate of lead, every three or four 
hours. The following is the formula I generally employ for such 
purposes : — 



R. Sacch. Saturn. £ij. 

Gum. opii. gr. vi. 

Conserv. Rosar. q. s. 
M, f. pil. xxiv. 



587. During the exhibition of the pills, the state of the bowels 
should be regarded; and should the febrile condition not be subdued 
by the evacuations already employed, we should again have recourse 
to the lancet. It will rarely happen that this state of circulation will 
not yield to this plan ; iruleed the very omission of the improper arti- 
cles which were before employed, will very much aid us in our en- 
deavours. After the system is freed from fever we shall find advan- 
tage in the employment of some gentle tonic ; the elixir vitriol, in 
doses of fifteen or twenty drops, three or four times a day, in strong 



180 LOCHIA, EXCESSIVE. 

red rose-leaf tea, properly sweetened, is a very useful, as well as 
grateful remedy.* It must be observed the acetate of lead may be 
suspended, if it does not considerably check the discharge in the 
course of five or six davs ; and should always be intermitted when 
the vitriolic acid is given. Should the complaint not yield to this 
plan in a reasonable time, I have seen much advantage from injec- 
tions per vaginam, of the acetate of lead and water, a little warmed, 
and thrown up, three or four times a day ; this should be made so as 
to have ten grains of the acetate to an ounce of water. The tincture 
of Secale Cornutum, I have found, of late, to be highly useful. It 
should be a saturated solution ; that is, three or four ounces of fresh 
powdered or bruised, Secale will bear a pint of white water to be 
poured on it, and allowed to stand for at least a week before using of 
it ; it should then be suffered to stand for two weeks longer, (shaking 
it frequently,) before it is filtered off, for use. Forty drops may be 
given of this every three hours : should painful contractions of the 
uterus come on, it can be given less frequently, or suspended until 
they cease ; it can be resumed, if necessary. It may be given in a 
little sweetened water or gruel. 

588. At other times the system seems to be rather prostrated by 
the profusion or the long continuance of the discharge ; when this is 
the case, the elix. vitriol, as above directed, should be given freely ; 
the tincture or extract of rathana will also be found highly useful, as 
will sometimes the alum whey: the parts should be bathed, as just 
directed ; the patient should be kept quiet, as above suggested ; and 
the injections be had immediate recourse to : this plan will generally 
prove quickly serviceable. 

589. There is another condition of the lochia, which is not only 
very troublesome, but from its offensive smell extremely loathsome ; 
this is where the coloured discharge has disappeared, but is succeeded 
by a profuse watery one, of a greenish colour; and from this circum- 
stance is called by the old women the " Green water :" it is frequently 
so acrid as to excoriate the parts over which it flows ; and always ex- 
tremely offensive in smell. The woman is almost always much debi- 
litated by this noisome evacuation ; and, in some few cases, I have 
seen a kind of hectic disposition supervene. 

590. The system almost always in these cases requires the use of 
tonics — the decoction of bark and the vitriol, should be freely given ; 
and the patient allowed a generous diet, with either ale or porter in 
moderate quantities at dinner. The parts should be frequently bathed 
with lukewarm water ; and injections of strong chamomile tea, in 
which a piece of quick-lime has been slaked and permitted to settle, 
should be used per vaginam, four or five times a day — these injections, 
like all others I have directed for the vagina, should be a little warmed. 

* A pint of boiling- water is to be poured on a half ounce of red rose leaves, and 
allowed to stand ; strain, as wanted, when cold — sweeten to taste, and give a wine- 
glassful, with or without the elixir vitriol as may be judged most proper. If used 
without the vitriol, it may be given every two hours. 



OF WASHING THE CHILD. 181 

The complaint, as far as I have observed, has always yielded to this 
plan of treatment. A chloruret of lime or soda is also highly useful, 
and may be used per vaginam three or four times a day. 

591. It may be thought incumbent on me to say something, on that 
condition of the lochia, where this discharge is too sparing — but I have 
already said, I look upon this as a favourable sign in the ordinary 
course of things : when it exists as a symptom of another complaint, 
that complaint must alone be considered. 



Sect. VII. — Of the Attentions necessary to the Child. 

592. Hitherto we have been considering the attentions due to the 
mother, together with some of the most common complaints attendant 
upon delivery: I shall now say a few words upon the demands of the 
child. Under this head, I shall first direct its washing ; 2dly, dressing 
of its navel ; 3dly, the medicines proper to purge off the meconium ; 
4thly, its food. 



a. — Of Washing the Child. 

593. The child's body when first born, is almost always covered 
with a tenacious unctious substance, which is rather troublesome to 
remove. It has been analyzed by Vauquelin and Buniva, and found 
most to resemble fat — they have not discovered any thing which readily 
unites with it. It is, however ascertained, that hog's lard answers 
better than any thing else that we know of to detach this substance 
from the skin. When the lard has become well incorporated with 
this coating, it can be removed by strong warm soap-suds, and a 
piece of flannel or sponge. It should be carefully taken off at the 
first washing, as it sometimes incrusts, and excoriates the skin, when 
this is neglected. The child, during this process, should not be un- 
necessarily exposed — if it be cold weather, it should always be washed 
near the fire ; and should be carefully dried after the washing. Many- 
nurses have a preposterous, and, as I believe, an injurious practice of 
using brandy or some other liquor, when they wash the child ; and 
especially when they wash the head — this practice should be forbid- 
den ; as I am persuaded that it has often-times been very injurious to 
the infant. After washing, the next thing to be attended to is, 



b. — The Dressing of the JVavel. 

594. Much ceremony was formerly observed in the performance of 
this office ; but it has now become a process of great simplicity, 
among the more enlightened part of the civilized world. It would 
be idle to enter into all the details suggested by ignorance, or craft, 



182 DRESSING OF THE NAVEL. 

for the due performance of navel- dressing. A variety of medicaments 
were, and in some places are still in use for this purpose ; all of 
which, to say the least of them, are altogether unnecessary. The 
only necessity for applying any thing to this part is, to prevent the 
dead navel-string from coming in contact with the skin of the child ; 
it would therefore matter not, as regards the cord itself, if it were not 
touched by any dressing. Dress it as we may, it will always sepa- 
rate at the umbilicus ; and our whole care should be to prevent this 
putrefying mass from excoriating the skin. The fact just stated, is 
highly interesting ; and it is especially so, since M. Billard, (Mala- 
dies des Enfans,) has very satisfactorily proved, notwithstanding, that 
the processs of separation is not the mere departure of a dead mass, 
from a living one, as has generally been believed. He declares that 
the 'cord of a living child does not putrefy, but that it first dries or 
shrivels up, and that this drying is an evidence that its vitality is the 
cause of it, and for the following reasons : 1st. That the drying of 
the cord, only takes place during the life of the child. 2d. That if 
the child dies before the cord is separated from the child, 
that this drying is immediately suspended. 3d. If the cord remain 
fresh, or the drying only commenced, the child has either been still- 
born, or has lived but a very short time. 4th. If the cord has be- 
come slightly dry, or even completely dry, the child has lived at least 
one day. And farther, in proof of this being a living process, 
he states, that the cord of a dead child never dies — it only putrefies. 
Thatthe dessication of the funis is farther proved to be a normal pro- 
cess and is of high importance to medical jurisprudence, it is a test 
whether the child has been born alive or still. This has not been 
well understood by medical men. It ought to be known to be a pro- 
cess of life, whenever it takes place ; for when the navel exhibits a 
shrivelled appearance it is proof (according to M. Billard) that the 
child has been born alive, and lived two or three days, especially 
when it is of a reddish brown colour, flattened and shrivelled, and its 
vessels dried and almost obliterated ; we may then safely infer it has 
been born alive, and lived some time after birth. On the other hand, 
when finding it soft, pulpy and of a green colour, and presenting 
other marks of putrefaction, the probability is the child has been bom 
still. The normal dessication only takes place during life, and may 
therefore be considered as a strictly vital process. So also a separa- 
tion of the cuticle may be considered, as a like vital process. Though 
the dressing of the navel is not strictly the accoucheur's province, 
nevertheless, as it may be required of him, he must not be ignorant 
upon a subject to which the world at large attaches so much conse- 
quence, however lightly he himself may think of it. 

595. All that is necessary, is to pass the remaining portion of the 
cord through a hole in the centre of a piece of linen rag, seven or 
eight inches in length, and about two and a half broad. After the 
cord has been passed through, it must be enveloped entirely by a 
bandage of ten inches long, and rather less than an inch broad, by 



PURGING OFF THE MECONIUM. 183 

passing it round, its whole length. The pierced piece of rag is 
placed lengthwise, as regards the child's body ; on this the wrapped 
up cord is laid, with its extremity towards the breast of the child; 
the inferior portion of the first rag is then folded over it, and the whole 
secured by the belly-band ; after this, the child is dressed as fancy 
directs, or as circumstances may force. 



c. — Purging off the Meconium, fyc. 

596. The propriety of purging off the meconium is no longer 
doubted, especially in hot climates. It has been found very much to 
lessen the mortality among the new-born children of the West Indies, 
and other similar climates, by preventing that very common, and but 
too often fatal disease, called the jaw -fall, or the trismus nacentium. 
This practice should never be neglected, even in this country. It 
might be difficult to say exactly, of what the meconium is composed; 
but it would seem certain, that bile is one of its constituent parts, agree- 
ably to the analysis of Vauquelin ; and the other, in part, is, the recre- 
ment of the secretion from the mucous membrane of the intestines; 
the finer parts having been absorbed.* This substance is sometimes 
of very considerable tenacity, and a dark bottle-green; this colour is 
derived from the admixture of bile. 

597. For the purpose of carrying off this substance, it is found that 
a little molasses and warm water is generally sufficient; I always order 
two or three tea-spoonsful to be given at once, and repeated from time 
to time, if the previous quantity be not sufficient — this rarely fails; 
especially when aided by the early secretion of the mother's milk.f 

* It would scorn to be proved, by a case related by Dr. Rees (on Costivencss, p. 137,) 
on ihe autbority of Mr. Hallam, that tbe meconium is a combination of tbe recrement 
of some digestion. perhaps bile, and a peculiar seen tion from the intestines themselves, 
(but perhaps, especially of the colon) and n> t the remains of food taken in after birth, 
or as some have apposed, of nourishment received by the mouth during- the stay of 
the foetus in utcro. Mr. H. delivered a patient of a "fine, muscular, fat, and healthy 
rhild, which had an impervious oesophagus, so that no food ever passed into the stomach. 
The child lived thirteen days ; but was so wasted that it- skin hung like a loose garment, 
and could be lapped and folded over its limbs. At first the child discharged ihe usual 
quanti'y of meconium from the bowels, ;,nd afterwards had. during i iglit days, one or 
two altine discharges, in quantify, colour, and consistence, not distinguish ible from the 
stools of children who take food in the usual manner. After the eighth day the fecal 
discharges became m re scanty and less frequent hut they continued to the last." 

i is just fallen under my own observation. A child was born with 
every external appe ranee of healthy conformation— but upon attempting to give it a 
little molasses and water it had nearly Strangled. Upon looking into its mouth, it was 
discovered there was no vault to it ; neither was th< re a ves'ige of soft pallet. It never 
swallowed a drop— indeed, every attempt was followed by such terrible distress, by the 
fluid passing into the trachea, that the trial was abandoned. It lived, however, ten 
days — became extremely ermciated and very yellow; yet it passed the meconium 
freely; afler which the evacuations were yellow. 

t This is an additional argument, tor the c irly application of the child to the breast ; 
since the first secretion of ihe breasts is of a purgative quality. This product is called 
"Colostrum." 



184 OF THE RETENTION OF URINE. 

Should this fail, the child becomes fretful and uneasy ; and oftentimes 
will moan, or cry loudly ; become sleepy ; frequently start : and by its 
complainings, show itself to be ill at ease. When we find this to be 
the case, we should inquire into the state of the evacuations ; and if 
these have not been sufficiently liberal, which is easily determined by 
their continuing to be tenacious and green, we should direct a small 
tea-spoonful of warm castor oil : this must be repeated, should it not 
operate in a couple of hours ; or a mild injection of warm milk and 
water with some molasses dissolved in it, will answer very well to aid 
the action of the oil. 

598. I must earnestly protest against the use of any acrid purgative 
for the purpose of carrying of! the meconium — nurses and midwifes 
are too apt to employ them, when this part of our duty is left to their 
discretion. I therefore, make it a rule to point out the remedy to be 
employed, without permitting them the smallest latitude. Their igno- 
rance frequently betrays them into indiscretions ; and this sometimes 
to the absolute injury of the child. I have too frequently witnessed 
this, not to feel it a duty to inveigh most pointedly against it. 

599. Dr. Buchan, in his pleasant and useful little work, " Advice 
to mothers," relates an anecdote so much in point, that I am induced 
to quote it at length : " I was once sent for by an intimate friend to 
look at a new-born infant, who appeared to be in great agony. I soon 
discovered the complaint was the belly-ache, caused by some injudi- 
cious purgative. As the midwife was present, I remonstrated with 
her on the rashness of thus tampering with an infant's delicate con- 
stitution. She replied, in a tone of self-sufficiency and surprise, ' Good 
God ! Doctor, I only gave the proper medicine to carry away the eco- 
nomy. ;' I should have smiled at her affectation of medical cant," 
adds the doctor, u and her ridiculous attempt to catch the word me- 
conium, had not the serious mischief she had done repressed every 
motion of laughter." A medical friend told me some time since, that 
he was called to a newly born infant, which was dying in great agony 
from a dose of aloes exhibited by the midwife. 

600. There is oftentimes much mischief arising from overpurgmg 
new born infants ; they, therefore, not only require very mild remedies, 
but proper doses of such remedies — and there is one rule by which 
these exhibitions should always be governed ; namely, that so soon 
as there is a change in the colour of the evacuations, all purgative 
medicines should instantly be withheld. 



d. Of the Retention of Urine. 

601. It very frequently happens with newly born children, that 
they do not pass their urine for many hours after birth; orso sparing- 
ly as to afford little or no relief: this creates a great deal of distress, 
and if not relieved by proper means, will sometimes occasion death. 
A very remarkable instance of this kind fell under the notice of my 
friend Dr. Parrish, and myself, which I will give in detail. Mrs. 



OF THE RETENTION OF URINE. 185 

was delivered of a healthy baby on the 15th June, 1822. On 

the 20th, in the evening, the child showed uneasiness, and on the 
21st it cried violently, and continued to be much pained until the 
25th. A variety of simple means were ineffectually used for the dis- 
charge of the urine, which had been either very sparing, or entirely 
suppressed, most probably from the 20th. On the morning of the 
25th, at ten o'clock, we found the abdomen very much distended, 
even to the scrobiculus cordis; the skin shining, and the superficial 
veins very much enlarged. The child had several very sparing 
stools, of a very dark green colour: two tea-spoonsful of castor oil 
were given in the course of the morning. At half past one o'clock, 
P. M., Dr. Parrish introduced a small flexible catheter and drew off* 
at one time eighteen ounces and a half of straw coloured urine. At 
seven o'clock of the same day, the child appeared perfectly relieved ; 
it slept soundly, and took nourishment freely ; two more tea-spoons- 
ful of castor oil had been given since the visit at noon, but without 
moving the bowels, nor did any water pass. As the child was easy, 
it was permitted to rest without disturbance. 

602. From this time until it died, (on the 28th,) the water was 
regularly drawn off by the catheter; the child, however, gradually 
declined from our first visit ; and its mouth became very sore; leave 
was not obtained to examine it. 

603. I have recorded this case for its great practical importance. 
I have seen several instances similar in their general appearances, 
and terminations ; which gives me strong reason to believe, that these 
children may have died of a retention of urine, though I was assured 
that they had regularly passed water — such was the statement for 
awhile, in the case just related ; and perhaps there may have been 
a small discharge, as always happens when the bladder becomes ex- 
cessively distended. This often takes place in the adult, from the 
same cause ; it is, therefore, a good rule to inquire into the state of 
the bladder, in all the complaints of very young children ; and we 
must not be too easily satisfied with the reports of the nurse upon this 
subject — I now make it my business, whenever I have any suspicion 
that the urine is not freely evacuated, to examine the abdomen of the 
child, especially if it be reported to be swelled. I carefully examine 
the region of the bladder, with a view to detect any distention of it, 
that I may take measures accordingly. I am disposed to believe, 
had the catheter been introduced twenty-four hours sooner, nay, per- 
haps twelve, the infant, whose case is related above, might have 
been saved — but as there was a constant assurance that water passed, 
there was no suspicion of the state of the bladder.* 

* M The introduction of the catheter is spoken of, in the case of a child ten days 
o'd. We never 'have had occasion t> employ the instrument at so early an age, and 
fear that its employment is more easily described on paper than carried into exe- 
cution in practice, particularly in tlie male." (Lond. Med. and Phys. Joum. Aug. 
p. 1-13.) 

In a case similar to the one which gave rise to the above observation, it may be 
asked, what other resource does our art afford ? I have not declared, nor even in- 

17 



186 OF FOOD FOR THE CHILD. 

604. I suggest, as a matter of probability, that the cases I have 
witnessed of death in very young children, where the abdomen has 
been much swoln; the superficial veins passing over it much distended, 
and very conspicuous, were similar affections of the bladder, though 
no such suspicion was entertained at the time. How far a distended 
belly, (indeed, almost to transparency,) with greatly enlarged veins, 
may serve to distinguish this state of the urinary organs in very 
young children, must be left to future observation. I felt it a duty 
to express this impression, with a hope it might awaken attention in 
those, whose province it is to witness many cases of sickness; espe- 
cially in very young children. 



Sect. TEH.— Of Food for the Child. 

605. The mother very rarely has her breasts furnished with milk, 
at the birth of the child ; for the most part there is an interval of 
several days, before it is supplied in sufficient quantity to sustain the 
infant— it is therefore, supposed, that the child would suffer severely, 
did it not receive nourishment by other means, until the mother is 
enabled to provide for it. Accordingly, an ample bowl is prepared 
by the nurse ; and the stomach of the child is crammed to regurgita- 
tion, with a tenacious paste, called pap, or panada. This is repeated 
with such mischievous industry, as to throw the poor infant into vio- 
lent agony ; unless its stomach revolt at the unmerciful invasion, and 
rejects it by a violent effort, and thus averts the impending mischief. 
Nature seems to have endowed the stomachs of children with a dis- 
criminating power, upon such occasions ; and most happy it is for 
them that she has been thus kind ; for, were it otherwise, many 
would die in a few hours after birth, from absolute repletion. 

606. It appears that the kind nurse has but one rule, by which she 
regulates the feeding of a newly-born child ; which is, to put food 
down its throat until its stomach can hold no more ; it is then permit- 
ted to rest a short time. But the delightful task of cramming is again 
resumed, especially if the poor babe cry: it is now imagined to be 
again hungry, and again its feeble powers of digestion are unmerci- 
fully taxed. This addition of food, to the great surprise of the anxious 
nurse, does not quiet its complainings ; and its uneasiness is now attri- 
buted to " wind;" and the unfortunate child is next obliged to swallow 
some stimulating tea, or liquor, until farther distention, and perhaps 
intoxication, are added to the already almost bursting stomach. It is 
then rudely jolted on the knee, until a kind vomiting comes to its re- 
lief; or until the bowels, rapidly and profusely discharge their con- 
tents, or until convulsions close the scene. 

sinuated, that the catheter should be used upon slight occasions ; but where the sup- 
prcssion is confirmed, and where every usual expedient has been resorted to, and has 
failed, should we suffer our patient to die, because the introduction of the catheter is 
difficult. 



OF FOOD FOR THE CHILD. 187 

607. Let us consider for a moment how small the stomach of a 
newly-born child is ; and how little will put it upon an uneasy stretch 
— passive, during the whole period of utero-gestation,* and contract- 
ed to its minimum size ; it is no sooner born than it is obliged to 
submit to be suddenly distended to almost giving way, from mistaken 
zeal. Can it then be a matter of surprise, that so many children are 
subject to pain, spasms, convulsions, and even death, a few days after 
they are born ? 

The stomach of the foetus is never required to digest any thing 
while in utero, as it is necessary it should do so for its own support, 
as the blood of the mother is every way ample for this purpose. This 
circumstance would seem almost proved by the experiment of Dr. 
Blundell upon a~dog. He supported a dog for three weeks, by in- 
jecting every day or two a few ounces of blood into the jugular vein. — 
Princ. and Pract. of Obstet. p. 96. 

608. What is the proper food for a child at this period ? — or should 
it have any ? There can be no objection to nourishment from time to 
time meted in proper quantities, and composed of proper materials. 
It must be recollected, that the nearer we follow nature in such cases, 
the nearer we approach to -what is right ; nature provides milk as early 
as circumstances will permit, and milk only — so, on our parts, we can 
imitate her providence sufficiently near to prevent mischief; and only 
milk should be given, until the mother herself be capable of furnish- 
ing adequate supplies. The article I am in the habit of recommending, 
is, cow's milk diluted with one-third water, with the addition of a 
little loaf sugar. Of this, the youngest child may take a few tea- 
spoonsful at a time, and this to be repeated as occasion may re- 
quire. 

* Dr. C. Lee has been making some interesting inquiries into the nature of the di- 
gestive process in the foetus while in utero, and upon which, he has come to the fol- 
lowing conclusions ; that "there is a digestive process carried on in the upper intes- 
tines of the foetus, similar to that which takes place after birth; and that the nutri- 
tion and growth of the fostus, are chiefly, or perhaps, entirely effected in this man- 
ner." He has ascertained that "the stomach of the foetus, from three to nine months 
old, invariably contains a transparent mucus and acid fluid, but never the smallest 
admixture of albuminous or nutritious matter, while, on the other hand, the upper half 
of the small intestines always contains a yellowish or orange-coloured pultaccous 
ma-s, which in appearance, as well as chemical composition, resembles exactly the 
chyme of the adult; in a word that it is nearly pure albumen. The contents of the 
lower half of I he small intestines contain a much smaller proportion of albumen lhan 
those of ihe upper half, and the matters gradually assume more and more the charac- 
ters of the contents of the large intestines, in proportion as the distance from the valve 
of the colon diminishes." 

A fluid resembling that contained in the duodenum has been detected in the he- 
patic ducts of the foetus ; from which it is inferred, that the liver of the foetus secretes 
the nutritious matter. This conjecture appears to be strengthened, from the great 
comparative size of the liver in the foetus ; and that this organ has never been found 
wanting in any case of monstro-ity yet examined. — Lond. Med. and l'hjs. Journal, 
for September, 1 - 

These facts show us how extremely small and unused to distention I he stomach 
of the newly-born child is; and warn us to be cautious not to put it too suddenly 
upon the stretch. They put to flight, besides, the agency of the liquor amnii in foetal 
nutrition ; and satisfactorily account for the recrement, called " meconium." 



188 OF NATURAL OR UNASSISTED LABOUR. 

609. The vulgar judge of the nutritious quality of a substance prin- 
cipally by its density ; hence, they are opposed to the simple food just 
recommended, because it does not possess this quality ; and they in- 
sist upon improving it, by the addition of some farinaceous article, 
but by which it is sure to be deteriorated : for almost all the children 
who partake of this improved substance, are sure to be afflicted with 
green and watery stools, if not with a full crop of aphthse. But, so 
soon as the mother is able to supply the demands of her infant, it 
should be confined to the product of her breasts, and to that alone, 
cseteris paribus. 

610. Many of the preparations in use as nourishment for young 
children, cannot be too strongly condemned ; such as crackers and 
water boiled together, and sweetened ; or bread, water, and sugar ; 
than which nothing can be more ungenial to the infant stomach — for 
these masses begin to ferment the instant they are received into the sto- 
mach. Green and watery stools, amounting in fact to diarrhoea, colic, 
sour eructations, or throwing up their milk strongly curdled, are almost 
the constant result of their employment. Besides, we must object upon 
general principles, to the use of any substance which needs to be 
made so warm as to require temperings for the child's mouth, by first 
entering that of the nurse. This is a horrible practice, and cannot be 
too severely reprobated. The child is thus obliged to take into its 

U-confirmed stomach, food, not only improper in itself, but which 
has the addition of a rank saliva from the nurse's mouth. 

611. Much care, we grant, must be taken in warming the food of 
the child, lest it be over heated, and its mouth made to pay the forfeit 
of the nurse's carelessness; but this can be done without any previous 
mouthing. 



CHAPTER XV. 



ON NATURAL OR UNASSISTED LABOUR. 

612. The classification of labours is altogether arbitrary ; scarcely 
two writers agreeing upon the same arrangement.* The object of 

* Hippocrates made only two classes, the natural and preternatural; Denman di- 
vides them into four classes ; natural, difficult, preternatural, and anomalous or complex; 
Hamilton follows the division of Denman ; Burns divides them, natural, premature, 
preternatural, tedious, instrumental, and complicated ; Baudelocque into three classes ; 
natural, manual, and instrumental; Dubois, Desormeaux, Boivin, Lachapelle, agree 
with Baudelocque, but include face presentations with the natural ; Conquest, Dewees, 
Blake, and Merriman, divide them into natural and preternatural ; Davis divides labours 
into natural, preternatural, complex, and instrumental; Ryan into natural, preterna- 
tural, manual, and instrumental." — It will be seen by the following statistics there is 



OF NATURAL OR UNASSISTED LABOUR. 189 

every classification is to aid the memory by tracing analogies ; to 
establish general rules from which particular ones may be deduced, 
and for the convenience of description. Now, these ends appear to 
be answered by almost any division that we may adopt, starting with 
some general definitions, and making every thing, as far as may be, 
conform to the generalization. There cannot, therefore, be any one 
employed which may not be liable, some to more, and others to fewer 
exceptions. I have carefully considered them all — some I would 
reject for their learned parade, without corresponding perspicuity; 
others, for their complication, and the want of harmony in their parts; 
others, for their multiplied distinctions without essential differences ; 
and others, for the incorrectness of their definitions ; experience being 
constantly at variance with them. 

613. The one in my estimation, least liable to objection, is that of 
Baud-elocque — I am persuaded that more correct practical notions can 
be collected by a proper study of his arrangement than from any other ; 
and I am also certain, that the younger practitioner well acquainted 
with his system, when placed at the bed-side, will give a more correct 
view of any given case ; will feel less embarrassment in deciding on 
the proper mode of treating that case, and will commit fewer mistakes 
in the absolute management of it than from the study of any other 
classification. In my view, it is as perfect as the nature of things will 
permit ; and I, therefore, from acting under it for many years, have 
adopted it. In pursuing this plan, I shall constantly feel that I am 
abridging the labour of the student; removing many of the difficulties 
of the young practitioner; and confirming the observations of the ex- 
perienced. "* 

614. A number of circumstances must occur that a woman carry 
her child to the full period of utero-gestation, and then give birth to 
it with the least possible trouble and risk. To secure the first, she 

a great propriety of adopting the divisions of labour. It is proved from the reports of 
various authors, and the repor's of Hospitals and other institutions, that there is pr 
prevalence of head presentations, being as 19,517 to 1757, (the htter being the aggre- 
:iumber of all other presentation^ ;) and that presentation which is the more fre- 
<;u nt (or 15 to lj is a numeric il calculation in this instance, is the first or most na- 
tural. 

The feet is next in frequency; the breech follows; then the last and less frequent 
r.re the knees. All other presentations are but deviations of the three fir-t. Of the 
61fi reported by Dr. Churchill, we may presume 550 were natural or- head presenta- 
tions. 

4 Hand descended. 
14 Feet descended. 
1 1 Breech. 

4 Arms. 

2 The funic. 
1 The Placentae. 

Thus we observe the head maintains the supremacy — so is it, in all the records v.e 
have examined. — Prin. and Prae. of 0\siet. />. 211. 

* Though 1 have adopted Baudelocque'a general arrangement, I have not rigorou*]*' 
<5bnfirrcd myself to it. This will he readily perceived, from the manner in which I 
have treated the various presentations. 

17* 



190 OR NATURAL OR UNASSISTED LABOUR. 

must be free from every cause capable of exciting the uterus to action ; 
or at least to that degree of action that would terminate in labour. 
And, for the latter, there must be present in the uterus itself, a healthy 
disposition to action ; and that disposition manifested previously to the 
commencement of labour, properly so called, by the subsiding of the 
uterus lower in the pelvis ; by a secretion of mucus ; by a kindly dis- 
position in the circular fibres of the uterus to relax, that the longitu- 
dinal need not be fatigued by too long acting ; and these contractions 
must be sufficiently powerful to make the child pass through the pelvis. 
There must also be a disposition in the external parts to yield, without 
the agency of much mechanical force ; there must exist a proper pro- 
portion between the opening of the pelvis and the diameter of the 
child's head ; and the latter must be well situated, that it may profit 
by the proper construction of the former; or, in other words, the great 
diameter of the child's head must constantly correspond with the great 
diameter of the pelvis. 

615. As all the circumstances essential to an easy and natural 
labour cannot be commanded, it must follow, that there will con- 
stantly be deviations from it ; and these deviations must be looked 
upon as so many exceptions to the several presentations, which Bau- 
delocque makes necessary to a natural labour. Baudelocque con- 
siders every labour natural, in which the woman might be delivered 
without help : and makes such consist of four principal presentations ; 
namely, 1st, the head; 2dly, the feet; 3dly, the knees; 4thly, the 
breech. 

616. It would be reasonable to conclude, that the presentations, 
which most frequently occur, are the most natural : now, these are 
found to consist of, 1st, those cases in which the child presents the 
head ; 2dly, those in which the breech offers ; 3dly, those in which 
the feet offer ; 4thly, those in which the knees offer.* Each of these 
general presentations is subdivided and forms varieties. 

617. Baudelocque is censured by some for the detail he enters into 
when speaking of his general presentations, and his subdivisions of 
them ; but in this their censure is misapplied. Every practitioner 
who is well acquainted with the form and dimensions of the pelvis, 
with the construction and various dimensions of the child's head, 
and with the mechanism of each individual labour, will be so far 
from condemning him, that he will admit that no man can practise 
with entire success, or complete usefulness, without a thorough 
knowledge of them. I agree, that to certain practitioners it will not 
only appear useless, but burdensome — those, for instance, who com- 
mit the whole charge of the labour to the management of nature, 
provided the head present, and this no matter how ; and as she is 

* For the reason just assigned, I have changed the order of Baudelocque's arrange- 
ment of the presentations constituting "natural labour." The frequency of the com- 
parative occurrence of the several presentations named above, will I believe, be found 
pretty constantly to stand in the order I have now placed them ; and this in my esti- 
mation, should be taken as the rule of division. 



OF THE PRESENTATIONS OF THE HEAD. 191 

usually successful, never stop to inquire whether they can aid her ef- 
forts, or abridge her toils : or those who consider the presentation of 
any one of the other parts above designated as essentially wrong ; 
and who will, in consequence, wrest from the hands of nature a 
labour, to terminate it by force, when she was every way competent 
to its accomplishment. Against the cavillings of such practitioners, 
I do not think it worth the trouble to defend him. 

61S. As regards myself, I am willing to confess, for the knowledge 
I possess upon the subject of midwifery, I am principally indebted 
to him : for to him do I owe the principles which rendered my ex- 
perience profitable ; and could I induce others who engage in the 
practice of midwifery, to study carefully this great man's works, I 
should benefit society, by rendering practitioners so much the more 
competent to fulfil the duties they have undertaken to discharge. 
Entertaining such sentiments of the author as I intend chiefly to 
follow, I shall not deem it necessary to apologize for my choice. 

619. In speaking of the presentations of the head, I confine my- 
self, like Baudelocque, to those portions of it designated by the name 
of the vertex or the posterior fontanelle ; and to that of the anterior 
fontanelle ; or, in other words, the particular or specific presentation 
is always indicated by these portions of the cranium. And when 
neither of these offers, so as to characterize the presentation, the part 
most easy to touch in the pelvis will always be designated by its own 
name : and all such will be considered as deviations from the pre- 
sentations of the head properly so called.. 



CHAPTER XVI. 

OF THE PRESENTATIONS OF THE HEAD.* 

620. Much speculation has been indulged in, to account for the 
frequency of "head presentations;" which eventually settled down 
in the belief that it arose from the greater weight of this part of the 
body, especially in the earlier periods of gestation. The validity of 
this assumption, has been called into question by M. Dubois, in a 
paper read before the French Academy of Medicine ; an analysis of 
which is presented in the Med. Chirurg. Review, for August, 1833, 
p. 235. In which, however, M. Dubois has not, in his explana- 
tion, in our opinion, been more fortunate than his predecessors ; for 
truly his attempt amounts to no explanation at all. For what ex- 
planation is there in ascribing the frequent presentation of the head 

* Agreeably to Madame Boivin, in the Maternite, of 20,517 children born in that 
institution, there were 19,810 head presentations. 



192 OF THE PRESENTATION OF THE HEAD. 

"to an instinctive choice of the' foetus, by which it could escape from 
its prison in the most ready manner, as the needle inexplicably turns 
towards the pole I" He had better have adopted the candour of 
Avicenna, in respect to the cause of labour, and said that God or- 
dered it, and it was so. The arrangement, for the greater security 
of the animal to be born, expelled or liberated, is not peculiar to 
the human race, for it is the same in the inferior animals, reptiles, 
and the oviparous products. Thus, Virey found, in the multiparient 
animals, that the snouts or noses were turned, in the horns of the 
uterus, towards the vulva ; in the viper, the mouths of the young 
were found placed towards the external parts ; so, in the egg, the 
head of the chick is always directed towards the big end. The 
same obtains in the ova of fishes ; so, also, in the larvae of insects - y 
the head always escapes first: the chrysalis eats through its shell, and 
the caterpillar through its silky covering. — (Dr. Ramsbotham.) 

The frequency with which the head presents, compared with any 
other part of the body, renders its various positions better known ; 
and also entitles them to be considered as the most natural : yet even 
head presentations have essential differences, as they are not all 
equally advantageous. Therefore, each variety should be well 
studied ; its distinguishing marks well ascertained, and its mechanism 
thoroughly comprehended. 

621. These presentations will be divided into six varieties; each 
of which has peculiar characteristics ; In the first presentation, the 
posterior fontanelle is behind the left acetabulum, and the anterior 

before the right sacro-iliac symphysis ; the head, therefore is placed 
diagonally as regards the superior strait : so also is the case in the 
second, fourth and fifth. In the second presentation, the posterior 
fontanelle is behind the right acetabulum, and the anterior before the 
left sacro-iliac symphysis. In the third, the posterior fontanelle is 
placed behind the symphysis- pubis> and the anterior before the pro- 
jection of the sacrum — in this, and in the sixth presentation, the great 
diameter of the. child's head offers itself parallel with the small dia- 
meter of the superior strait. In the fourth the anterior fontanelle is 
behind the left acetabulum, and the posterior before the right sacro- 
iliac symphysis. In the fifth, the anterior fontanelle is behind the 
right acetabulum, and theposterior before the left sacro-iliac symphy- 
sis. The sixth is the reverse of the third. 

622. Some have objected to these divisions, 1st, as being per- 
plexing to the memory; 2dly, and this without' conveying any es- 
sential practical information. To the first, it may be answered, that 
the whole of them can be Teamed, by pursuing, the course I shall, lay 
down, as quickly almost as they can be read ; and the same observation 
will apply to all the other varieties of natural labour. * 

623. Let it be remembered, first, that the 1, 2, and 3 presenta- 
tions of the head, are all represented by the posterior fontanelle ; and 
the 4, 5, and 6, by the anterior fontanelle ;. secondly , that in de- 
scribing, these presentations, we constantly follow, their numerical; 



THE FIRST PRESENTATION. 193 

order : thirdly, that we always commence with the left acetabulum ; 
then go to the right acetabulum, and next to the symphysis pubis, 
whether it be the posterior fontanelle or the anterior, that is to be re- 
presented — this will make the first presentation have the posterior 
fontanelle behind the left acetabulum, the second behind the right 
acetabulum, and the third behind the symphysis pubis. Then as I 
have just stated, the other three take their character from the anterior 
fontanelle, and follow precisely the same route, or order — of course, 
the fourth will have the anterior fontanelle to the left acetabulum, the 
fifth to the right acetabulum, and the sixth to the symphysis pubis. 

624. As regards the second objection, that " this division conveys 
no essential practical information," I can only lament the imperfect 
knowledge of the objector of what is absolutely required of every one 
who attempts to pursue midwifery, if he cannot profit, and that ma- 
terially, by the divisions and distinctions of Baudelocque ; for I 
maintain, that the excellence of one accoucheur over another, almost 
exclusively depends upon the accuracy of his knowledge of the diffe- 
rent presentations. 

625. I have already earnestly recommended to the inexperienced 
practitioner, to study the different presentations carefully ; and to take 
the fontanelles, and not the ears, for his guide, (89.) The vertex, 
therefore, will be distinguished from any other part by its roundness, 
its firmness, its sutures, and its fontanelle. The particular position of 
the head relatively to the pelvis, (and this constitutes the species of 
presentation,) is only to be determined by the position of the fonta- 
nelles, and the direction of the sutures : to determine this, however, 
it is only necessary to ascertain the situation of the fontanelles. 



Sect. I. — Of the First Presentation, and its Mechanism* 

626. In the first presentation, the posterior fontanelle places itself 
behind the left acetabulum, while the anterior offers before the right 
sacro-iliac junction ; the sagittal suture must, therefore, traverse the 
superior strait obliquely. For the position of the trunk and other 
parts of the child, I refer to Plate V., and explanation, at the end of 
the volume. 

627. The head of the child, in this presentation, offers itself in an 
oblique position as regards the superior strait; by the contractions of 
the uterus the vertex is made to sink lower in the pelvis than any 
other portion of the head, and at the same time places the chin of the 
child upon its breast. The head descends in this state of anterior 
flexion, in the axis of the superior strait,f until it is arrested by the 

* Of 20,51 7 head presentations, observed in the Maternite, 15,682 were first pre* 
sentations. 

+ It must be borne in mind, that the head of the child never engages in the superior 
strait, in a perpendicular or vertical position ; for this cannot happen, and coincide 
with the direction of the opening of this strait, since this is at an angle of about 30°, 
and, consequently, the head must enter this opening at the same angle. 



194 THE FIRST PRESENTATION. 

sacro-ischiatic ligaments of the left side, the sacrum or perinseum. 
When the head arrives at the first part, it would remain stationary, 
did not its relations with the pelvis, at the lower strait, change in such 
manner as to force the posterior fontanelle to offer itself to the arch of 
the pubes — in doing this, there is a slight twist or pivot-like motion 
executed at the expense of the neck, which may be estimated at a 
sixth or eighth of a circle. During this change in the direction of the 
head, it must be recollected, that the trunk does not perform a simi- 
lar movement. 

628. In proportion as the head is urged forward, the lambdoidal 
suture is to be more distinctly felt below the symphysis pubis ; and if 
the head be not unusually large, the pelvis a little contracted, or the 
sacrum too straight, the centre of the occipital bone will be found to 
correspond with the symphysis pubis ; but if either of these cir- 
cumstances obtain, it will be perceived to answer to the leg of the 
left pubis, and ischium. At this moment, the chin of the child, which 
had hitherto been placed on its breast, begins to depart from it : the 
vertex advances and separates the external parts, by engaging under 
the pubes, and rises up towards the mons veneris ; the inferior edge 
of the symphysis pubis answers as a kind of axis for the head to turn 
on ; in doing this, the head describes about a quarter of a circle back- 
ward. For the head, in issuing from the pelvis, obliges the chin to 
describe an extensive curve passing successively over the whole of 
the central line of the sacrum, coccyx, and perinseum; while the ver- 
tex itself passes through but a small space. So soon as the head has 
escaped through the external machinery, the face is found to turn al- 
most always towards the right thigh. 

629. The shoulders are now to deliver themselves ; which they do 
in the following order — the right shoulder advances towards the pubes, 
while the left is placed before the sacrum, and isvby the force of the 
pains made to descend lower and lower until its point issues from the 
bottom of the vulva, while the right is freeing itself from under the 
pubes. When the shoulders are delivered, the rest of the body fol- 
lows immediately. 

630. " By following," says Baudelocque, " step by step the course 
I have just traced from observation, it will appear, 1. That at all pe- 
riods of labour, the head presents its smallest diameter to the pelvis, 
and that it passes through it, presenting only its smallest circumfe- 
rence. 2. That it executes three different motions in its passage ; 
that of flexion forward, in the first period ; the pivot-like or rotatory 
motion in the second; and lastly, that of flexion backward, at the 
time it disengages from under the pubes." Vol. I. p. 362. See 
Plate VI. 



SECOND AND THIRD POSITIONS. 195 



Sect II. — Of the Character and Mechanism of the Second Position* 

631. The mechanism of the second position is precisely the same 
as that of the first, if we change the position of the vertex, and place 
it at the right acetabulum, instead of the left. In consequence of the 
right lateral obliquity of the uterus prevailing so often, and the rectum 
not passing immediately down the centre of the sacrum, and being 
occasionally impacted with hardened feces, this presentation is not 
quite as favourable as the first — but we rarely find in practice any- 
essential difference between them ; for we may always control the ob- 
liquity of the uterus, by placing the woman upon her left side; and 
can empty the rectum by an injection, as is my uniform practice, 
■when I find tilings thus situated. See Plate VII. 



Sect. III. — Character and Mechanism of the Third Position.^ 

632. In this presentation, the posterior fontanelle answers to the 
symphysis pubis, and the anterior to the projection of the sacrum ; 
and where a proper relation exists between the head and pelvis, 
this presentation is not attended with more difficulty, perhaps than the 
two former positions ; provided neither the right nor the left lateral 
obliquities carry the head from the centre of the pelvis ; for the ver- 
tex will be found to descend behind the symphysis pubis, while the 
chin will mount upwards, and place itself against the breast, as in the 
former cases ; in consequence of this, the head will only present its 
pependicular diameter to the small diameter of the upper strait ; and 
when the vertex has arrived at the bottom of the pelvis, the occipital 
bone will be found to offer itself to the arch of the pubes, and will 
pass through the external parts as in the first and second presentations. 
The shoulder will now present, but there will be no certainty, whether 
it will be to the right or the left. See Plate VIII. 



Sect. IV. — Character and Mechanism of the Fourth Position.^] 

633. This position is by no means so favourable as either of those 
just described ; for the forehead must come under the arch of the 
pube^, in consequence of the anterior fontanelle being to the left 

* Of twenty thousand, five hundred and seventeen head presentations, three thou- 
sand, six hundred and eighty-two were second presentations. 

t In twenty thousand, five hundred and seventeen cases, there were but six of this 
presentation. 

t Of twenty thousand, five hundred and seventeen births of head presentations, 
there wcrebnt WJ of this presentation. We presume this means where the head was 
delivered without having its character changed or converted into the second presenta- 
tion, either spontaneously or designedly; as the head must have offered originally 
much oftcner in this position. 



196 FOURTH POSITION. 

acetabulum, and the posterior to the right sacro-iliac symphysis. In 
order that the head may pass on, it must descend until a portion of 
the right parietal bone rest upon the inferior part of the sacrum ; 
when there the pivot-like motion mentioned (627) in the other pre- 
sentations must take place, if every thing go on well, and by the 
same mechanism. This motion, however, in this instance, is such, 
as to place the forehead under the arch of the pubes, by sliding along 
the left side of the pelvis. 

634. In consequence of the forehead being placed under the arch 
of the pubes, the anterior fontanelle will be found in the middle of 
the arch and the posterior above the point of the sacrum. The head 
being urged by the pains, descends still lower in the pelvis, and 
makes the posterior fontanelle pass over the coccyx and perinseum ; 
while the anterior and forehead are confined, as it were, to the arch 
of the pubes. Indeed, it mounts a little behind the symphysis; as 
the anterior part of the head has not the same relation to the arch as 
the occipital region ; therefore, the anterior fontanelle becomes al- 
most stationary, while the posterior continues to advance, and stretch 
the perinseum, which presently, slips over the occiput, and retires 
with its edge to the child's neck, and, like the same part when under 
the arch of the pubes in the former presentations, becomes the centre 
of motion, and permits the occipital region to turn backward towards 
the anus of the mother ; at the same time the face disengages itself 
from under the pubes. In this instance, as in the former, the chin is 
made to describe a curved line, but in a contrary direction. 

635. So soon as the chin is liberated from the arch of the pubes, 
and appears without, the face of the child, by half a turn, places 
itself towards the left thigh of the mother ; at the same time the 
shoulders descend, and the left is found under the pubes, while the 
right moves towards the sacrum, and is first disengaged from the 
vulva. See Plate IX. 

636. This species of labour is necessarily more difficult and pain- 
ful than those we have just considered ; and it oftentimes becomes 
extremely so, if the head be either relatively or positively large for 
the pelvis. It requires, in some instances, many hours to accomplish 
a labour, that would have been speedily terminated, had either of 
the first two been the presentation ; more especially, if resisting soft 
parts should be added to the other difficulty. Baudelocque thinks 
that the right lateral obliquity would also increase the evil of this 
presentation ; but this I believe can be surmounted, by placing the 
woman upon her left side. This labour is always of longer duration 
than where the vertex presents ; and of course the woman's suffer- 
ings are increased, in proportion to the duration: now, as we almost 
always have it in our power to reduce both this and the fifth, one to 
the second, and the other to the first, we should always do so when 
nature does not do it for us. Nor is this change of position of the 
head an operation of the slightest difficulty to the accoucheur; neither 
does it cause the smallest pain to the patient ; provided advantage be 



FOURTH POSITION. 197 

taken of the proper conditions of the uterus, and head of the child, 
and the state of the labour. For the uterus must be well dilated, the 
membranes ruptured, the head occupying the lower strait, and the 
labour active. When these pre-requisites obtain, the point of the 
fore-finger must be placed against the edge of the sagittal suture either 
before or behind the anterior fontanelle; and in the absence of pain, 
this part must be pressed towards the left sacro-iliac symphysis, and 
maintained there during the subsequent contraction of the uterus. 
Should this first attempt fail in changing the position of the head, by 
bringing the posterior fontanelle to the right acetabulum, the attempt 
must be repeated again and again until it succeed ; which it will al- 
most constantly do. 

637. I consider a perfect knowledge of this presentation, (for it is 
far from being unfrequent,) a matter of high moment to the practi- 
tioner ; and particularly so in this country where the study of mid- 
wifery engages so much of the attention of the medical student, and 
where every one, almost, who enters upon the practice of physic, 
must also become a practitioner of obstetrics. So positive an ad- 
vantage does a knowledge of this presentation, and the mode of re- 
ducing it, give one practitioner over the one who may be ignorant of 
it, that it enables the first to terminate a labour in as many minutes as 
the other might be hours. 

638. So decidedly useful is the knowledge of the fourth and fifth 
presentations, to the patient, that I hold that man incompetent to 
practise midwifery in its best manner, who cannot detect, and change 
this mal-position of the head, and thus abridge sometimes, by several 
hours, the misery and pain of his patient. I therefore look upon Dr. 
Denman's* advice as unfriendly to the improvement of midwifery 
when he says, " When the membranes break, if the os uteri be fully 
dilated, the child, though resting at the superior aperture of the pelvis 
either sinks by its own gravity, if the woman be in an erect position,! 
or is propelled by the continuance of the same pain by which they 
were broken ; or, after a short respite, the action of the uterus re- 
turns, and the head of the child is brought so low in the pelvis, as 
to press upon the external parts ; properly speaking, upon the internal 
surface of the perinacura. In its passage through the pelvis, the head 
of the child, which at the superior aperture was placed with one ear 
to the ossa pubis, and the other to the sacrum, or with different de- 
grees of diagonal direction, undergoes various changes of position, 
by which it is adapted to the form of each part of the pelvis, with 
more or less readiness, according to its size, the degree of its ossi- 
fication, and the force of the pains. With all these changes, whether 

• Introduction, Francis's ed. p. 232. 

+ Dr. Denman is certainly wron^, when he supposes that the child's head will sink 
into the cavity of the pelvis by its own gravity, if the woman be standing; for when 
she is erect, the head finds a resting place on the anterior ini^in of the pelvis. See 
note to par. 027. 

18 



198 FOURTH POSITION. 

produced easily or tediously, in one or many hours, the practitioner should 
on no account interfere, provided the labour be natural." 

639. Agreeably to this advice, we are not to interfere, though the 
head present in either the fourth or the fifth presentation; though we 
can by an opportune and well-directed force, shorten the woman's 
sufferings perhaps many hours ; especially with a first child ; and th 
without offering the slightest violence to either mother or child. Na- 
ture, indeed, sometimes, though not sufficiently often, operates this 
change herself; and is this not sufficient to justify the practitioner to 
imitate her ? I have always done this since I first became sensible of 
its advantages ; a period, now, of nearly forty years, unless the labour 
has been too far advanced to permit a change, which has not been 
oftener than three times during the whole of the period stated. In 
doing this, I am well assured that I was but performing a duty, by 
shortening, as well as moderating the woman's sufferings — indeed, 
so convinced am I of the propriety and utility of this " interference," 
that I should hold myself culpable did I neglect to take advantage of 
this important hint of nature. 

640. The propriety of changing this and the fifth position of the 
head cannot be questioned, when a moment's reflection is bestowed 
upon its mechanism. Yet neither Dr. Denman, nor any of his friends, 
appear to have been acquainted with the proper mode of treating 
these cases. And it is truly a matter of surprise that they should 
have been unwilling to receive information from their neighbours upon 
this important point of obstetric practice ; for they certainly were in 
possession of the works of Baudelocque,* in which he so scientifically 
and successfully treats of this subject. It is true that Dr. John Clarke, 
about the year 1800, seems to have accidentally caught a glimpse of 
the proper manner of conducting such labours. I say a u glimpse ;" 
for it was but little more, as he confounds the fourth and fifth presen- 
tations with the sixth ; and does not appear to think or to know there is 
a difference in their natures or mechanism. He confesses that chance 
first led him to the knowledge of the fact, that in some cases this po- 
sition of the head can be remedied without subjecting the mother to 
any additional pain, or the child to any kind of danger." He adds, 
that " everybody who has been engaged in the practice of midwifery 
knows, that if in labour the face of the child lies towards the symphy- 
sis pubis, that considerable difficulty is thereby frequently occasioned." 
Now, this situation of the face constitutes, properly speaking, the sixth 
presentation, which certainly could not be intended, since he speaks 
of this position as one of frequent occurrence, a circumstance denied 
by all the best writers upon the subject. " In l'Hospice de la Mater- 
nite," the sixth presentation is acknowledged to have occurred but 
once in twelve thousand one hundred and eighty-three labours. 

641. It is farther evident that he confounds these very different 
presentations, when he says " If, on examination, the anterior fonta- 

* Baudelocque was translated by Heath, and published in 1790. 



FIFTH POSITION. 199 

nelle be felt, and the sagittal suture be found running from it towards 
one of the sacro-iliac joints, or directly towards the concavity of the 
os sacrum, there remains no doubt that the face will be born towards 
the symphysis pubis. 

642. Now, the direction of the sagittal suture constitutes two es- 
sentially different presentations, and requires very different modes of 
treatment, as it may be towards the sacrum, or one of the sacro-iliac 
junctions. Moreover, the fourth and fifth presentations are of com- 
paratively frequent occurrence ; while the sixth, as we have just stated, 
is extremely rare. Agreeably to the same returns above mentioned, 
in the same number of labours, the fourth occurred forty times, and 
the fifth two and twenty. 

643. Again, Dr. Clarke is not exactly right, when he says, " if the 
anterior fontanelle be felt, and the sagittal suture be found running 
from it, (tlie symphysis pubis,) towards one of the sacro-iliac joints, 
or directly backwards to the concavity of the os sacrum, there re- 
mains no doubt but that the face will be born towards the symphysis 
pubis ;" for the fourth and fifth presentations sometimes reduce them- 
selves to the first and second ; a circumstance which cannot possibly 
occur in the sixth. 

644. Again, Dr. Clarke is but partially right when he asserts "it 
is unnecessary to observe that this alteration will be more easily pro- 
duced when the face lies towards the groin, tha 11 when the sagittal 
suture runs directly backwards towards the sacrum ; but even in this 
case the change may be effected with much more facility than I before- 
hand supposed it possible;" for we must declare that neither Dr. 
Clarke, nor any other man, ever succeeded in bringing the vertex 
under the arch of the pubis, when the sagittal suture ran directly 
from the symphysis pubis towards the sacrum, as in the case of the 
sixth presentation. See plates VIII. , IX., X., and also the account 
of the management of the sixth presentation. 



Sect. V. — Character and Mechanism of the Fifth Presentation* 

645. All the relations of the child's head, and that of the pelvis, 
are the same in this as in the one just spoken of: we have only to 
imagine the anterior fontanelle to the right acetabulum, and recollect 
the mechanism of the fourth vertex presentation, to be in possession 
of this ; but in this presentation a little more difficulty may be expe- 
rienced than in the fourth, owing to the contingencies, (636) which 
may make the second not so favourable as the first, as has been al- 
ready stated. When the head escapes from the vulva, the face will 
turn towards the right groin. Nature sometimes reduces this case to 

* In 20,517 head presentations, it offered only ninety-two times in the fifth. The 
remark on the number of 4th presentations, will apply equally well to the fifth. 



200 SIXTH PRESENTATION. 

a first presentation, and thus teaches us a salutary lesson. See Plate 
IX. 



Sect. VI. — Character and Mechanism of the Sixth Presentation* 

646. This presentation is of most rare occurrence ; having met 
with but three instances of it ; two of which were twin cases ; but 
from the smallness of their heads, the}' created no delay in the labour. 
They happened, in both cases, to be with women who had previously 
borne children. The third instance was under the care of a midwife ; 
but as it was one of much longer duration than the woman had before 
experienced, and as the pains were very frequent, severe and in- 
effectual, my advice was asked. I found the head still at the superior 
strait ; the anterior fontanelle was immediately behind the symphysis 
pubis ; the scalp was very tumid, and pushed forward and downward. 
I waited for the effects of two or three pains, which I found did 
nothing more than to push the swoln scalp a little lower in the pelvis, 
but "without advancing the head, though the efforts were very strong. 
I passed up my hand, and turned the anterior fontanelle towards 
one of the acetabula, and then committed the case to the natural 
powers ; which pretty soon accomplished the delivery. 

647. The character of this presentation is exactly the reverse of 
the third ; that is, the anterior fontanelle is placed behind the symphy- 
sis pubis, and the posterior before the sacrum. There are two cir- 
cumstances connected with this position, which render it less favour- 
able than" either of the other positions : 1st. The great diameter of 
the head, being parallel to the small diameter of the upper strait. 2d. 
The forehead being under the absolute necessity of coming under the 
arch of the pubes; for in this presentation, we cannot, as in the 
fourth and fifth, change it to the second or first, as I shall have occa- 
sion to observe elsewhere. See Plate X. 

648. The occiput, in this presentation, descends along, and before 
the sacrum, until it arrives at the inferior part of the os externum ; 
pressing the perinseum before it, until it escapes through the external 
parts ; it then turns immediately backward, as described in the fourth 
and fifth species of vertex presentation. 

649. It would be easy to multiply the presentations of the head, as 
Baudelocque justly observes, were it of any practical importance ; but 
as this is not the case, it would only tend to embarrass, rather than 
answer any profitable purpose. Mathematical precision is not required 
in such cases, especially as the mechanism of the labour is not al- 
tered ; for, when the posterior fontanelle is at all in advance of the 
sacro-iliac junction, either right or left, it will almost always eventually 
place itself under the arch of the pubes, and this is all that is neces- 
sary. 

* Only 2 cases occurred in this presentation, out of 20,517 deliveries. 



PART II. 



OF LABOURS, IN WHICH THE CHILD PRESENTS THE VERTEX, BUT REN- 
DERED DIFFICULT OR PRETERNATURAL. 

650. I now commence, agreeably to the plan proposed, with the 
consideration of the causes which may render a natural labour pre- 
ternatural or difficult, but which can be terminated by the hand alone 
as well as the mode of operating in such cases. I shall exclude from 
this division, such causes, which of themselves would render the use 
of instruments necessary or proper, they being to be considered under 
another head. 



CHAPTER XVII. 



CAUSES OF PRETERNATURAL LABOURS. 

651. Many causes may render a natural labour, a preternatural 
one ; or it may be essentially bad from the beginning, owing to the 
untoward situation of the child. They may, therefore, be both acci- 
dental and unavoidable. Among the causes we may enumerate, 1st. 
Flooding ; 2dly. Convulsions ; 3dly. Syncope ; 4thly. Hernia ; 5thly. 
Obliquity of the uterus; Gthly. Partial contractions of the uterus; 
7thly. Compound pregnancy ; Sthly. Descent of the cord ; 9thly. 
Too short a cord; lOthly. Bad position of the head; llthly. Ex- 
haustion ; 12th. Hemorrages from the lungs or other organs. 

652. A labour may commence with every prospect of being speed- 
ily and successfully terminated ; but after a continuance for a longer 
or a shorter time, with the fairest promise, the patient may be as- 
sailed by some accident, which puts in jeopardy her life, or that of 
the child, or both, and from which nothing can save them, but the 
well-directed and timely interference of art. One of the most com- 
mon, and at the same time, one of the most alarming, is 

18* 



202 FLOODING. 



Sect. I. — 1. Flooding. 

653. In treating of flooding in this place, we shall confine our 
considerations to the subject in question ; or in other words, as an 
indication in a natural labour ; and where that indication points out 
no other remedy than delivery by turning, or other manual inter- 
ference. A flooding may take place after labour has commenced, 
under two different conditions of the os uteri : first where it is but 
partially dilated, and rigid ; secondly, where it is dilated, or easily 
dilatable. 

654. These two conditions are by no means indifferent ; they are 
of great practical importance, and should never be confounded, or 
overlooked. 

655. Should hemorrhage take place in the early part of labour, 
and before the os^uteri is sufficiently well opened for the purposes of 
delivery, we should not think of immediate delivery ; as there can 
be no absolute necessity for hasty or rash interference while the 
uterus is in the condition here spoken of, it would be the height of 
imprudence to enter the uterus by force, for the purpose of turning. 
Indeed Baudelocque (system, Vol. II. par. 1809.) says, and I fully con- 
cur with him, " Whatever abundance of blood the woman may lose, 
nothing could justify the conduct of the accoucheur who would per- 
sist in endeavouring to deliver without delay ;" for it would only be 
creating new difficulties, instead of relieving the existing one. 

656. The mode of proceeding in such cases, is, first, to attempt 
moderating the discharge, by rest, a horizontal posture, by blood- 
letting if the pulse be full, by the exhibition of pretty large doses of 
the acetate of lead, by cold applications, but above all, by the tam- 
pon.* Second. By promoting the contraction of the uterus, should 
the above means fail, by rupturing the membranes, as directed by 
Puzos: but under the restriction suggested, when treating on this 
point. See Chapter on Uterine Hemorrhage, "Diseases of Fe- 
males." 

657. Should the hemorrhage take place when the os uteri is well 
dilated, or easily dilatable, we should proceed to turning ; provided 
the rupturing of the membranes have not abated the discharge. Or, 
should the flooding have commenced after the waters have been eva- 
cuated, if the quantity threaten the life of the mother or child, and 
the child's head is at or near the upper strait ; and provided, also, 
the natural powers of delivery do not advance the head sufficiently 
fast to give a promise of a speedy delivery.! Should the signs 

* In using the tampon, it is never necessary to stop the mouth of the uterus, as 
recommended by Leroux, Baudelocque, and others ; it is every way sufficient, that 
the vagina be occupied by a sponge of a sufficient size — the mouth of the uterus be- 
comes filled pretty quickly by a coagulum, if the tampon is as successful as might be 
anticipated. 

t It has been advised by some, when we have so far succeeded in turning as to 



CONVULSIONS. 203 

which would render turning the best mode of terminating the 
delivery not be present, we must have recourse to the forceps.* 
The mode of operating with them in particular presentations, will be 
pointed out under each respective case. See Chapter on For- 
ceps, &c. 

Sect. II. — 2. Convulsions. 

65S. This alarming disease may attack a woman after labour has 
commenced, and under precisely the same conditions of the uterus 
as I have stated above, (655.) Should they attack while the uterus 
is but little dilated, and rigid, we should not think of attempting the 
delivery of the child ; as it would be as mischievous in this, as in the 
former case. Our first attempt should be to moderate the force, and 

bring the feet to the passage, that we should wait some time, before we finish the ope- 
ration. Dr. Davis is the latest authority for this practice : he observes, " It is a fact, 
which must have often occurred to practitioners of experience to observe, that the ope- 
ration of turning is for the most part immediately followed by a cessation of the he- 
morrhage. The change thus effected on the situation of the child in utero being- 
made, it is generally both unnecessary and improper to proceed hastily to complete 
the delivery ; which, therefore, it would be often much better to delay for an hour or 
two, to wait a favourable disposition of the soft parts, than to undertake it imme- 
diately after having brought down the feet into the birth." — Elem. Oper. Med. p. 160. 

I cannot by any means agree to this advice; and for the following reasons: — 1st. 
Because I have never recognised as a fact, that "the operation of turning is for the 
most part immediately followed by a cessation of the hemorrhage ; that is, the mere 
change of position of the child ; for there can be no possible reason why it should 
be so, unless it give greater opportunity for the tonic power of the uterus to exert it- 
self; and this can be as certainly effected by simply rupturing the membranes. 2d. 
In a hemorrhage of such extent as would require turning as a remedy, the patient can 
never be considered safe until the uterus is empty, that the tonic powers of this organ 
can effectually arrest the discharge. 3d. After we have been forced to enter the 
uterus, I believe it to be the soundest practice to finish the delivery, slowly and care- 
fully ; especially as I never attempt to turn in such cases, until there is u a favourable 
disposition of the soft parts " to permit delivery ; as I am certain, it never can be abso- 
lutely necessary to interfere until then. — See Chap, on Uterine Hemorrhage ; Diseases 
of Females by the author. 

* Dr. Davis intimates, rather than enforces the use of the forceps, under circum- 
stances, which my reasoning upon the subject, as well as my experience, leads me to 
fear ; namely, where the head is high in the pelvis. He says, " In cases of hemorrhage 
occurring at an early period of labour, there could, indeed, be no impropriety in having 
recourse to the use of forceps of more than ordinary length, provided the state of the 
orifice of the uterus as to dilatation, was such as to be compatable with the safe em- 
ployment of any kind of instrument on the principle of the forceps. In some few casea 
of this description, the fetal head being only about to engage at the brim of the pelvis 
there might occasionally be some difficulty in determining: on the choice to be made be- 
tween an operation with the forceps and that of turning." 

Now in my estimation, there can be no hesitation about the choice of means — the 
forccp3 must not be thought of, in this situation of the head : turning is the proper 
remedy ; for the hemorrhage will itself remove the only difficulty in this case ; namely, 
the obstinate contraction of the uterus. Besides, between turning and the application 
of the forceps, there is no comparison : the art of turning, if it be performed with at- 
tention to the rules laid down, is very much more easy (consequently,) more safe, 
than the application of the forceps. The dexterity and skill of this gentleman might 
make them the safer plan ; but it must be observed, we do not write for gentlemen 
of his experience — we write for them who are but moderately or not at all ex- 
perienced. 



204 SYNCOPE. 

diminish the frequency of the convulsions, by blood-letting, and the 
other means recommended in the chapter upon this subject, until the 
uterus has become softened, or dilated ; then, provided the natural 
powers be not sufficiently active, or competent to the finishing of the 
labour, we should proceed to turn. 

659. Should the uterus, however, be dilated, or easily dilatable, 
and the convulsions threatening, especially if the pains are not of suffi- 
cient force or efficacy, we should, immediately after a copious bleeding, 
proceed to the operation of turning, with a view to diminish the in- 
jurious tendency of the convulsions upon the head. But should the 
w T aters be long drained off, and the head low in the pelvis, and inva- 
riably, should it have escaped from the mouth of the uterus, the for- 
ceps are exclusively indicated. See Chapter on Puerperal Convul- 
sions. 



Sect. III. — 3. Syncope, 

660. I have seen several instances where the pains of labour were 
regularly followed by syncope. In these cases, this condition of the 
system did not seem to interrupt the progress of the labour in the 
slightest degree : this affection was constitutional, and such as would 
follow, in these patients, from any great excitement or alarm, or from 
pain or temporary exhaustion. 

661. M. Travers says, " a person suffering acute pain, is in no 
danger of syncope."* This is true during the continuance of pain, 
for the most part, but there are exceptions ; w T e have seen fainting take 
place during the extraction of a tooth, and during the cutting in a 
severe operation. But during labour we have never known syncope 
to take place during the painful contraction of the uterus, though it 
may quickly follow the cessation. This, as we have observed, appears 
to be owing to some peculiarity of the nervous system, and does not 
interrupt the return of subsequent contractions. 

662. In cases like those just mentioned, we never think of inter- 
fering with the natural progress of labour. But when these faintings 
take place where peculiarity of constitution will not account for them ; 
where they are attended with increasing exhaustion; where the labour 
pains diminish both in force and frequency ; where faintings become 
more permanent in their duration ; and where the pulse flags, or be- 
comes nearly extinct, it behooves the practitioner to discover, if pos- 
sible, the cause, and as quickly as may be, to remove it. 

663. Dr. Davis, (Elem. of Oper. Mid. p. 171,) relates the follow- 
ing very interesting case of syncope. " A poor woman a patient of 
the Royal Maternity Charity, under the care of an intelligent midwife, 
after having been in labour for about five hours, became suddenly 
very faint upon the bursting of the foetal membranes, and the discharge 

* Constitutional Irritation, p. 268. Am. ed. 



SYNCOPE. 205 

of a considerable quantity of liquor amnii, whilst being supported in 
a sitting attitude on a chamber utensil, she was making an effort to 
respond to one of the calls of nature. She was immediately laid 
down in a horizontal posture ; but upon farther adjustment of her 
person and bed-clothes, she was found to be perfectly dead." The 
body of the deceased was carefully inspected on the following day ; 
but no cause could be discovered for the sudden death. 

664. An internal hemorrhage* is, perhaps, the most frequent cause 
of this alarming condition: when it proceeds from this source, it al- 
ways commences gradually ; that is, the debility is not suddenly 
induced ; nor are the syncopes at first profound ; but both may in- 
crease in proportion to the extent or force of the remote cause. f The 
abdomen is observed to enlarge ; sometimes there is a slight external 
hemorrhage, or discharge of serum a little tinged with blood ; the 
pains slacken ; and the woman becomes exhausted. 

665. In cases like these, there appears to be but one remedy ; which 
is immediate delivery by turning, provided the uterus be in the con- 
dition already sufficiently often indicated, to permit this operation ; and 
if not, I am pretty certain there is not that necessity for instant delivery, 
that would put at defiance the rules I have endeavoured to inculcate 
against forcibly entering the uterus for any purpose — for it must be 
recollected, that after labour has commenced, and made some little 
progress, and especially if the woman has gone to the full period of 
utero-gestation, the disposition to syncope is oftentimes favourable to 
the dilatation of the os uteri, or at least renders it so pliant as to be 
penetrated by a little force — when this is so, turning is the best re- 
medy ; but we must take care to secure the tonic contraction of the 
uterus, before we attempt the delivery of the placenta. 

666. BaudelocqueJ relates cases of concealed hemorrhage which 
are highly interesting, and well worth consulting. From what he 
relates upon this subject, it would appear that a hemorrhage of this 
kind may take place long before, as well as near the period of nine 
months ; and that the immense distention which the uterus suffers 
from the influent blood, provokes it to contraction, and brings on la- 
bour pains. But as the cause which may produce indicative syncopes, 
cannot always be ascertained ; and as it is rational to suppose it is in 



* Baudelocque, System, par. 1113, relates a case of syncope from a very large calcu- 
lus in the gall-bladder. 

t 1 was called to a poor woman, whom I found dead upon my arrival, from this 
kind of hemorrhage, joined to an external one — but as the latter was not sufficient to 
cause death, and as it was declared by the midwife, and the women who were present, 
that the abdomen was enlarged after the discharge became appirent, and as this had 
been arrested by some means or other, I suspected an internal hemorrhage to be the 
cause of her death. Leave was obtained to inspect the body, and my suspicions 
were confirmed. In this case the hemorrhage took place some hours after the labour 
had begun ; but there was a suspension of pain soon after, and most probably at the time 
the hemorrhage took place, as the woman had said she was now easy, and wished to 
go to sleep. , 

t System, par. 1081, 1083, 1084. 



206 HERNIA. 

some way or other connected with labour ; it will be well, under 
proper conditions of the uterus, to turn, and thus remove a difficulty, 
if not the cause of the faintings. Should this occur when labour is 
far advanced, or when turning would be improper, the forceps may be 
used.* (See Chapter on Forceps.) 



Sect. IV. — 4. Hernia. 

667. Hernias of long standing, are sometimes in danger of be- 
coming strangulated from the excessive force of labour — if this take 
place, we are obliged to deliver by turning, when the natural powers 
seem to be too tardy for the situation of the hernia' — the time when 
this is to be attempted, as regards the condition of the uterus, has 
already been pointed out. I will, however, illustrate this by the re- 
cital of an interesting case. Mrs. had laboured under an unre- 
duced umbilical herniaf for eighteen years ; it gave her trouble when- 
ever she neglected her bowels, or was imprudent in diet. When I 
was called to her she was in labour with her tenth child — she was a 
very corpulent woman, and always suffered from a great anterior ob- 
liquity of the uterus ; her labours were wont to be both tedious and 
severe. Upon this occasion, it was uncommonly slow and painful; 
much uneasiness had been experienced in the hernial tumour from 
time to time during the whole day but towards evening, (about twelve 
hours after her labour had fairly commenced,) it became more and 
more severe, particularly after each pain — fearing what might happen, 
I had ordered her a full dose of castor oil, in the early part of the day; 
and this was followed by a brisk purgative injection ; the latter pro- 
cured a copious evacuation of feces, but the oil had no effect. Vo- 
miting now ensued: this was followed by a disposition to syncope, 
and other alarming symptoms, arising, as I supposed, from a disposi- 
tion in the hernial contents to become strangulated. I mentioned my 
opinion with candour to the friends of the patient, and proposed im- 
mediate delivery as the most probable means of preventing farther 
mischief, though I confessed I was by no means certain it would be 
absolutely effectual. The os uteri was now sufficiently dilated to 

* I have already remarked, (659,) that turning is never to be attempted, when the 
head has escaped from the orifice of the uterus. 

t On this subject, Dr. Blundell, says, " the womb, when large, taking its place above 
the brim of the pelvis, the intestines generally lodge above and behind: so, that if a 
woman have been labouring under a hernia that is reducible, whether femoral or in- 
guinal, the descent of the gut may be prevented by the interposed womb; and^thus it 
has happened, that women who have been liable to hernia, by a repetition of preg- 
nancy, have been kept, in good measure, free from it : women, however, sometimes 
labour under irreducible hernia of the femoral kind, and when they become 
pregnant with this disease upon them, there is always a risk of strangulation ; the 
nterus enlarging, presses the intestines backwards and upwards ; and of consequence, 
it gradually brings the gut to its bearing on the upper margin of the orifice of the sac, 
so that all the symptoms of strangulation are produced. — Princip. and Pract. of Obstet. 
p. 87. 



OBLIQUITY OF THE UTERUS. 207 

permit the operation with propriety ; the membranes were entire and 
every thing favourable for the attempt. The patient was placed, as 
will be directed by and by; the hand was passed, the membranes 
ruptured, and the turning- performed in the course of a few minutes 
with the most entire success ; the placenta was delivered in due time. 
A full dose of laudanum was now given : the vomiting and sickness 
of stomach were immediately relieved by the delivery — less pain was 
experienced in the tumour, and all the unpleasant symptoms seemed 
to vanish after a copious evacuation from the bowels, procured doubt- 
less from the oil, which fortunately had only been retarded, and not 
interrupted by the laudanum. My patient's recovery was as rapid as 
was usual with her. She died about twelve years after, of strangu- 
lated hernia. 

66S. Should the symptoms which would render immediate delivery 
necessary, not occur until the head is low in the pelvis, the waters 
long drained off, or the head arrested by bad position, or if it have 
escaped from the os uteri, the forceps are exclusively indicated, 
(See Chapter on Forceps.) 



Sect. V. — 5. Obliquity of the Uterus. 

669. The deviations of the uterus, under the name of obliquities of 
this organ, have already been pretty fully treated of — (see 298, &c. ;) 
but it very rarely happens that either of them alone is the cause of a 
preternatural labour, though it may complicate it very disagreeably. 
(See Baudeloeque's cases, par. 298.) I have but once found it 
necessary to turn for this cause ; and this was a very small woman, 
with rather a contracted pelvis, who laboured under the most exten- 
sive anterior obliquity I ever remember to have seen. She was placed 
upon her back, with her shoulders lower than her hips ; the belly was 
supported by a towel, and the hands ; but nothing seemed sufficient 
to make the head engage in the pelvis. The pains were extremely 
severe, and very frequent ; and the poor creature suffered for many 
hours to no purpose. Seeing no prospect of delivery taking place 
from the exertion of the natural powers, I thought it best, after due 
consideration, to terminate the delivery by turning — this was accord- 
ingly done, with perfect success. 



Sect. VI. — 6. Partial Contractions of the Uterus. 

670. By these we are to understand the contractions of the external 
or inferior edge of the mouth of the uterus, as well as that portion 
which, in the unimpregnated state, constitutes the internal edge, or 
orifice of this organ, round the neck of the child ; so as to prevent the 
descent of the shoulders. The first of these conditions is the most 
serious in its consequences, because it is more difficult to remedy. 



208 PARTIAL CONTRACTION OF THE UTERUS. 

In this case the head of the child has escaped through the external 
ring which constitutes the mouth of the uterus ; in consequence of 
which the neck of the uterus retracts itself behind it, and being no 
longer stretched by the bulky part of the head, it contracts ; and this 
so strictly sometimes, as to embrace the neck — when this takes place, 
the shoulders cannot pass the barrier which the contracted neck offers, 
and they are thereby arrested, and their form is but ill- calculated to 
dilate again the mouth of the uterus ; for now, it can only be opened, 
by mechanical means. 

671. In the second case, the head remains enveloped in the lower 
portion of the uterus, (which portion in the unimpregnated state con- 
stitutes its neck,) while the internal edge contracts round the neck of 
the child, but not so strictly ; and thus is offered on all sides an in- 
clined plane for the shoulders to rest upon. This contraction is much 
more frequent than the former ; and is, for the most part, the greatest 
obstacle we have to encounter, when we attempt to turn, after the 
waters have long been drained off. It will readily be perceived, that 
it is essential to either of these cases, that the waters be discharged ; 
and, as far as my own experience will justify the remark, neither of 
these contractions takes place, but after the lapse of a considerable 
time ; at least, to the degree that would seriously obstruct delivery. 

672. These cases necessarily result from the constant disposition 
which the uterus has to return to its original size and shape, after the 
distending cause is removed ; and this, as I have elsewhere observed, 
is owing to its constant tendency to accommodate itself to the shape 
and inequalities of its contents, by virtue of its tonic power — hence 
the contractions in question. 

673. When either of these conditions complicates the labour, it 
will soon become for many hours stationary, or nearly so ; and what- 
ever other cause may combine with the existing one, to render imme- 
diate delivery either desirable or indispensable, it will be found almost 
impracticable to perform it by any means. If we attempt to turn, we 
shall find it almost impossible to insinuate the hand into the orifice of 
the uterus, so as to dilate it sufficiently to permit it to pass to the feet; 
and if we apply the forceps, we can only deliver at the risk of tearing 
the uterus; especially in the first of these cases. In the second, Bau- 
delocque says, (System, par. 1118,) "though it may in some cases 
produce as great an obstacle to delivery, it is always easier to over- 
come it, and the same inconveniences do not result from it ; because 
the head is not so far engaged, and may always be pushed back ; 
which permits us to advance the hand under the uterine circle in ques- 
tion, and dilate it." I do not altogether agree with this high authority 
on this point; for I have certainly met with this case, where I could 
not push back the head, and thus dilate the stricture ; and also, I have 
found there was no possible advantage in merely overcoming this re- 
sistance by passing the hand through the contraction, so long as the 
stricture continued in force, after the hand was thus passed. For if 
the contraction be not entirely removed, or so weakened as to yield 



PARTIAL CONTRACTIONS OF THE UTERUS. 209 

to a moderate force, there is nothing gained by bringing down the feet 
to the orifice of the uterus, or even lower ; for the instant the breech 
descends to this stricture, its progress is arrested by the inclined plane 
I have just spoken of; and no force that could safely be exerted, will 
make it pass through this narrowed portion of the uterus. 

674. Of the first of these cases, I can find but one upon my records ; 
nor have I any recollection that I have ever encountered more. Bau- 
delocque says he has seen but one ; it must, therefore, be of rare oc- 
currence. Of the second I have witnessed many ; indeed, I believe 
it will be almost always found where the waters have been long eva- 
cuated, and when the pains are feeble and transitory for many hours 
after. I have rarely failed to find it, when it has been expedient to 
finish a labour by turning ; where tediousness and other causes have 
rendered this interference necessary. And it is one of the most usual, 
as well as one of the most obstinate and insurmountable causes, which 
oppose turning in the contracted uterus. 

675. These cases maybe suspected whenever there is no advance- 
ment of the labour, though the pains be very severe ; and there is 
neither a contracted pelvis, nor a bad situation of the head, nor a 
rigidly closed os uteri to account for the delay — where, during the 
pain, the head is found to descend, and gives temporary assurance 
that delivery will take place pretty soon : but where these hopes are 
instantly destroyed by the head being quickly retracted, so soon as the 
pain shall cease to urge it downwards.* And they may be ascertained 
by passing the hand beyond the head of the child — in the first case 
the lower circle of the os uteri will be found round the child's neck; 
in the second, the higher circle will be found in the same situation. 

676. Lest this should not be accurately comprehended, we shall 
again advert to the neck of the uterus, when this organ is either not 
impregnated, or not beyond the sixth month — in either case, the neck 
of the uterus will be found to have two openings, or rather two cir- 
cles; the one inferior, or that which constitutes the os tineas ; the other 
superior, and constitutes the upper part of the neck, or the inferior 
portion of the body of this organ, (107.) At the latter end of gesta- 
tion, the neck is entirely effaced, (200 :) but no sooner is the distending 
cause removed, than the fundus, body, and neck, set about moulding 
themselves into their original form ; and consequently, in such a manner 
as will indicate the portion which will ultimately become neck. This 
being the case, the whole of the portion which forms this part will 
contract, so soon as the distending cause is removed : now, if the head 
has entirely passed through the lower circle, this part will contract, 
because distention is removed ; and as the neck is much smaller than 
the head, it will close round it, and form the first case in question ; 
but if the head is but in part through the lower circle, the upper 

* This case must not be confounded with the retraction of the head which take9 
place when the parietal protuberances are about to pass below the tubers of the ossa 
ischia; and supposed by some to indicate too short a funis — this last takes place only 
at the last period of labour ; whereas the other occurs before the head occupies the 
lower strait. 

19 



210 PARTIAL CONTRACTIONS OF THE UTERUS. 

circle will contract at the part opposite the neck, and form the second 
case. 

677. The management of these cases is by no means so well under- 
stood, as to free them from all embarrassment, even to practitioners 
of considerable standing : this has arisen perhaps from their not having 
been w T ell described by any author with which we are acquainted ex- 
cept Baudelocque ;* and his account is defective as regards the treat- 
ment, as it does not inform us how we are to overcome the constriction, 
after the hand has passed it ; for if we do not find means to relax it, or 
very much abate its force, the breach cannot be made to pass. I will 
point out the mode I have pursued in such instances, by relating a 
case extracted from my " Essay on the Means of lessening Pain," &c. 
p. 137. 

678. " 1798, December 18th: I was called to Mrs. Z ,in labour 

with her third child ; she had been in pain for forty-eight hours ; waters 
discharged thirty-six ; the uterus well dilated ; pains severe, but no 
advancement of the child ; during the pain, the child's head, which 
was well situated, would be forced down, but as soon as it ceased it 
would again be retracted ; this had been the case many hours before 
I saw her. In order to ascertain the cause of this delay, I introduced 
my hand into the uterus, and presently found the cause of the child not 
advancing ; a circle of the uterus had closed between the shoulders of the 
child and its head, which prevented the former from passing. I bled 
her to fainting; pains soon came on, and she was quickly delivered." 

679. This case terminated without the necessity of turning ; but I 
have not always been so fortunate, as some cases have required this 
operation, and others the forceps. The value of this case consists 
chiefly in showing the very decided efficacy of blood-letting, and has 
been quoted for this purpose principally, as it is the remedy which 
should always be employed in such cases, and should be carried to 
the extent mentioned. It is the only remedy with which I am ac- 
quainted, that has a decided control over the contracted uterus ; it is 
one almost certain of rendering turning practicable under such circum- 
stances, if carried to the extent directed — a small bleeding in such 
cases is of no advantage ; for, unless the practitioner be determined 
to carry it to its proper extent, which is a disposition to, or the actual 
state of syncope, he had better not employ it. 

680. Turning must not be thought of in the first of these species, 
as the head is without, or escaped through, the os uteri ; the forceps 
are the only proper remedy in this case : but before they are employed, 
the same precaution of an extensive bleeding should be premised, or 
otherwise the most serious mischief may follow — for either the uterus 
would suffer a laceration at the stricture, or it would be dragged through 
the external parts with the child's shoulders. 

681. The cases in which I have the oftenest experienced the good 
.effects of blood-letting, were of the second kind of :iny division; but 

* System, Vol. II. p. Ill, par. 1117, 1118. 



COMPOUND PREGNANCY. 21 1 

as I am certain, from what I have seen, it would be equally proper, 
and equally successful in the first — in reasoning upon the subject, I 
should a priori, think it would be, if possible, more so in the first 
than in the second species ; as there are fewer fibres concerned in that 
portion of the uterus which forms the stricture; and besides, we have 
the most ample experience of its good effects, in the rigid state of the 
os uteri, before it has become dilated. 

6S2. When bleeding is determined on, the blood should be drawn 
from a large orifice, and the woman placed upon her feet, if practi- 
cable — much less blood will answer, if the bleeding be conducted in 
this way. 

Sect. VII. — 7. Compound pregnancy. 

683. When pregnancy consists of twins, or of more children, it 
will be found that the uterus does not, nor indeed cannot, act as fa- 
vourably for their expulsion, as if there was but one child. The reason 
of this is obvious even with twins ; since, in such cases, the uterus 
cannot close upon the whole surface of a child at once ; its force is 
consequently exerted in such a manner as that both children must 
receive a part of the influence ; and both of course, will be pressed 
equally, or nearly so, towards the opening of the pelvis, but in which 
both cannot engage at one and the same time. This, in some cases, 
will create a difficulty from the very commencement of labour; which 
cannot always be overcome by the natural agents of delivery ; the 
labour will, therefore, be protracted, as well as painful; and some- 
times no alternative is left but artificial means, to finish the labour ; 
hence, the frequent necessity to interfere — this case will sometimes 
require turning, at other times merely bringing down the legs, &c. 

684. Embarrassment may sometimes be created even in the best 
positions that twins can take ; and this will, consequently, be in- 
creased, when they offer untowardly at the opening of the pelvis ; 
when one or both may be hydrocephalic, or have the abdomen loaded 
with water; when there shall be more than two children; when two 
may be joined together, creating a monster, &c. No distinct rules 
can be laid down for the management of such cases; interference 
almost always becomes indispensable, but the precise mode of acting, 
must be left very much to the good sense and discretion of the ac- 
coucheur. 

685. Independently of the obstacles arising from the compound 
nature of the pregnancy, or the awkward situation of the children 
which compose it, this labour, like every other, may be complicated 
by any of the accidents already enumerated, and thus require imme- 
diate delivery. But should interference be considered indispensable 
to the relief of the woman, it must not be carried into execution before 
the uterus is in a proper condition, as has been constantly insisted 
on, in every other case in which it is necessary to pass the hand into 
it, for the purpose of delivery. See Chapter on Twins, &c. 



212 TOO SHORT A CORD. 

686. Should the nature of the case be such as to render turning 
either improper or impracticable ; that is, if the head of the child can- 
not be easily moved up, in consequence of its being wedged by 
another child ; or so low, that it would be dangerous, after the long 
escape of the waters to attempt turning ; or after it has escaped from 
the neck of the uterus, we must then terminate the labour by the for- 
ceps. 



Sect. VIII. — 8. Prolapsus of the Umbilical Cord, Sfc. 

687. It is a matter of some surprise, that the case now under con- 
sideration should not occur more frequently than it does ; since, we 
do not perceive that any part of the economy of labour, or the na- 
tural order, or disposition of the foetus and its cord within the uterus, 
appear calculated to prevent it ; yet, comparatively, a prolapsus of the 
cord is an event of rare occurrence. With respect to its becoming 
a case of preternatural labour, it is only to be considered such while 
there is circulation in the cord ; and when there is evidently a risk of 
this being interrupted, before delivery can take place by the natural 
agents, in time to save the child. When this occurs, turning maybe 
had recourse to — 1st. When the uterus is sufficiently dilated or easily 
dilatable ; 2d. W T hen the head is enclosed in the uterus, and the wa- 
ters have not been too long discharged ; 3d. When there is no de- 
formity of pelvis to defeat the object. Should the forceps, however, 
be at hand when the head is low, and the cord in danger of compres- 
sion, or actually compressed ; we should without hesitation employ 
them. See Chapter on Prolapsus of the Cord. 



Sect. IX.— 9. Too Short a Cord. 

688. It is said that too short a cord, either natural or artificial, will 
interrupt a natural labour, and oblige us to finish it by turning. I 
shall not positively deny the existence of such a condition of the 
cord ; b/ut I must say, I have never seen an instance ; and also, that 
I entertain strong doubts of its possibility. See Chapter on prolapsus- 
of the Cord. 



Sect. X. — 10. Of the Bad Position of the Head, though the' Vertex 

may present* 

689. It is not simply because the vertex presents, that this labour 
is in general esteemed the best — it can only be considered strictly so, 

* It istruly a matter of surprise that a man of Dr. Montgomery's experience and 
reading, should give as a noveliy what he terms " the transverse malposition." — Baud e . 



BAD POSITION OF THE VERTEX. 213 

when the great diameter of the child's head shall correspond with that 
of the pelvis, and while this part maintains a certain position in its 
course, as well as describes a given route in that course — therefore, 
the third and sixth presentations must be essentially bad ; since with 
them the reverse of a good presentation obtains ; that is, the great 
diameter of the head oflersto the small diameter of the superior strait, 
in both cases ; besides the sixth having the disadvantage of the fore- 
head coining under the arch of the pubes. 

690. But if the head present in the best possible manner at the su- 
perior strait, it gives no absolute security it shall continue so ; since 
it may depart from the route which is essential to an easy labour. 
Therefore, the labours in which the vertex presents, may require inter- 
ference from four different causes : a. From the vertex presenting to 
the small diameter of the superior strait, as happens in the third and 
sixth presentations, b. From the chin departing from the breast too 
early ; though at first a proper relation existed between the head and 
pelvis, c. From the presence of the face ; owing to the excessive 
departure of the chin from the breast, or the retiring of the vertex to- 
ward the back. d. From some part, as the hand, or arm, accompa- 
nying the head ; though the latter was at first well situated. 



a. Bad Position of the Vertex. 

691. In the third presentation of the head, the vertex offers to the 
pubes, and the anterior fontanelle to the sacrum. Should the pelvis 
be ample, or the head not too large, which virtually amounts to the same 
thing, the natural powers concerned in labour will be every way com- 
petent to its accomplishment ; but should the reverse obtain, great 
difficulty may be experienced ; or the labour may be even impracti- 
cable, without extraneous assistance. AVhen the difficulty to deliver 
depends exclusively upon position, we have nothing to do, but to 
change it, to remedy the evil; and then commit it to nature, provided 
she appear immediately competent to this end — that is, if the pains 
are effective, and the labour advances with sufficient rapidity to justify 
its being trusted to the natural powers. (See 694.) 

692. When we are about to rectify the position of the vertex, the 
woman must be placed, as will be directed by and by ; the hand in- 
troduced into the vagina; the head grasped by insinuating the thumb 

locque fifty years or more ago describes it, and in almost the very words of this author ; 
and describes also the same mode of rectification, and the same consequences should 
you fail of restoring the chin to the breast, and the facility with which the head 
passes out, when adjusted. If Dr. M. is ignorant of Baudclocque's directions on this 
point, he failed in necessary or careful reading ; if he has read it, he has failed in his 
customary liberality in Dot giving cr.jdit for it As to the mention made of it by myself, 
and dwelt on at some lengtb, his ignorance of it would not surprise me ; as my work 
is not in the hinds of so many as that of Baudclocque's ; to say nothing of the high 
authority of that author, through all Europe where midwifery is cultivated. 

I differ a little in my directions for its adjustment as will be seen in this section of 
my work, but that is totally another matter. See sect. 6 of this sect. 

19* 



214 CHIN DEPARTING TOO EARLY FROM THE BREAST. 

and fingers within the the orifice of the uterus, in such a manner as 
the fingers shall lie on one side of the head, and the thumb on the 
other ; the head must then be raised, so as to disengage it from the 
superior strait, and the vertex turned towards one of the acetabula — 
if the right hand be used, turn it towards the right acetabulum; if the 
left, to the left acetabulum ; and then trust the rest to nature. 

693. But should any of the accidents already enumerated compli- 
cate the labour, and render delivery immediately necessary, we must 
turn, and deliver by the feet ; provided the os uteri be in a proper, 
condition. 

694. If it be the sixth presentation, we must proceed as directed 
above, (692 ;) and reduce the situation of the head to either the fourth 
or the fifth ; and then commit it to the natural powers for fartherance. 
It must be remembered, that when the sixth presentation is changed 
to the fourth or fifth, w T e must not attempt its farther reduction, as re- 
commended for these presentations, when they originally offer in these 
positions ; as this attempt, if even successful, as regards the alter- 
ations of position, will necessarily destroy the child, by the excessive 
twist the neck must undergo in the operation. Should any of the ac- 
cidents mentioned above complicate the labour, we must turn, and 
deliver by the feet; as directed for the third presentation, (691.) Or, 
if the waters have long been expended, or the uterus in a state of 
inertia, we must give the ergot, or apply the forceps. See Chapter 
on Forceps. 



b. Chin departing too early from the Breast. 

695. When treating of the mechanism of labours of the vertex, I 
remarked that the chin rested upon the breast of the child (627,) until 
the vertex or forehead was about to emerge from under the arch of the 
pubes ; and that this position of the chin was essential to a natural, or 
easy labour : when the chin does not confine itself to the breast until the 
proper time for leaving it, the longitudinal diameter (87) of the child's 
head will offer to the small diameter of the lower strait, at the last 
period of labour ; and thus present almost insuperable difficulties to 
delivery. 

696. This case is known at the beginning of labour, by the anterior 
fontanelle being found in the centre of the pelvis ; and, at the last 
period, this by part being at the bottom, or rather the lowest part of the 
child's head, and resting on the internal face of the perineum ; by 
one of the parietal protuberances offering to the arch of the pubes ; 
and by the forehead being placed on one side of the pelvis, but the 
side to which it will offer will depend upon whether it was a first or 
fifth, or a second or fourth presentation, that was disturbed. If either 
of the first two, the forehead will be- to the right side ; if either of the 
latter two, it will be to ike left. 



CHIN DEPARTING TOO EARLY FROM THE BREAST. 215 

697. Various causes have been assigned for the production of this 
very untoward situation of the head : Levret supposed it was owing 
to the shoulders being arrested at the superior strait, in consequence 
of the oblique situation of the child's body ; while Baudelocque con- 
tends it arises from the direction of the expulsive forces of the uterus, 
and the manner in which they act upon the child's head ; and this 
opinion appears to be well founded. 

69S. The indication in this situation of the head is to restore the 
chin to the breast ; this may be effected at two different periods of the 
labour: first, where the head has not descended entirely into the 
lower strait ; and secondly, where it occupies the lower strait. As 
regards both inconvenience and certainty, the first situation of the 
head is preferable to operate upon ; and, where practicable, should 
be chosen. But, to act with success, it is necessary that the os 
uteri should be well dilated, the membranes ruptured, and the pains 
sufficiently brisk. The mode of acting in this case is very simple ; 
first, rectify the obliquity of the uterus by placing the woman upon 
the side opposite to the deviation, if either the right or the left lateral 
obliquity prevail ; or upon the back, if the anterior : secondly, in 
the absence of pain push up the forehead, and maintain it in that po- 
sition by making a fulcrum of the points of two or three fingers ; 
when a pain comes on, maintain the resistance, by supporting the 
forehead with the fingers, until the vertex is found to descend, and 
the forehead to rise in the pelvis ; when this is done, the delivery of 
the head may be trusted to nature. I believe it will not always be 
necessary to introduce the whole hand, in the first condition of the 
head, though perhaps absolutely necessary in the second. 

699. Baudelocque recommends acting upon the forehead in the 
time of pain ; I am aware it is rarely safe to differ from this high au- 
thority ; yet I am equally convinced, it is occasionally proper to do 
so — and the case we are considering is one in point ; first, because, 
did we act in time of pain, we should be under the necessity of over- 
coming its force before we could raise the forehead ; this, of course, 
would be a work of supererogation ; secondly, by acting in the ab- 
sence of pain, we can by a very small force, carry the forehead as 
high as we wish, and can maintain it in the position we desire it to 
take, by an exertion scarcely greater than would be sufficient to raise 
a weight equal to that of the child's head ; thirdly, the vertex will de- 
scend as a matter ofcourse, if the forehead be prevented from doing so ; 
fourthly, by acting during pain we are obliged to carry the forehead 
in direct opposition to the action of the uterine forces, which when 
the uterus firmly embraces the head, are so entirely in the direction in 
which the forehead would descend, that we should only raise the 
forehead, without giving any opportunity for the vertex to fall into the 
pelvis. 

700. In the second situation of the head, we are to be governed 
by the same principle*, but they are more difficult to be put in execu- 
tion ; in this case, it is essential to success, that we raise the forehead 



216 



CHIN DEPARTING TOO EARLY FROM THE BREAST. 



in the absence of pain ; and particularly, if the head have escaped the 
orifice of the uterus ; when this is the case, it requires the introduction 
of the hand to raise the whole head: this should always be done, first, 
that we may be certain of keeping the forehead sufficiently high to 
permit the vertex to descend. After we have raised the head suffi- 
ciently towards the superior strait, we must place the extremities of 
the fingers against the posterior edge of the frontal bone, and make 
them serve as fulcra, as in the first instance, (698.) In doing this, 
we should carefully avoid pressure upon the anterior fontanelle itself. 
When the position is rectified, we must withdraw the hand, and let 
nature perform the rest. 

701. I have dwelt upon this case, because it is one of great con- 
sequence to both mother and child — for if it be improperly managed, 
the child will too often fall a sacrifice to the method employed, and 
the mother will incur the risk which always attends embryulcia. For 
it is a case in which the forceps would fail to relieve, since the head 
cannot be made to leave the pelvis in the direction it has descended 
to the lower strait ; for the longitudinal diameter will be found parallel 
to the small diameter of this strait. Turning will be rarely possible, 
were it resolved upon ; since in the second situation, the person who 
has charge of the case, and who must be supposed ignorant of the 
principles which should govern it,* will permit a great deal of time to 
pass, after the escape of the waters, under the hope that every pain 
will deliver the head, because of its nearness to the opening of the 
pelvis ; he will at this time most probably find the head free from the 
mouth of the uterus, in which case- turning must ever be forbidden, 
or if it have not, the uterus will be so firmly contracted upon the body 
of the child, as to render this operation impracticable ; embryulcia is 
then the only resource of such a practitioner. 

702. I will endeavour to illustrate this subject, by the relation of a 
case. Mrs. was under the care of a young practitioner of mid- 
wifery, with her fifth child. Her labours were ordinarily rapid, and 
her health and constitution excellent. She was attacked early in the 
morning, in the usual manner of her labours ; and her accoucheur gave 
her a promise of speedy relief; her pains .were strong and frequent ; 
the uterus was well dilated ; and the membranes burst soon after his 
arrival. Every expectation was entertained that the patient would 
soon be delivered ; the head of the child had descended to the inferior 
strait ; but after a short period, the head was found not to advance. 
Still supposing that nothing could prevent the delivery of a head so 
near to the world, he constantly gave encouragement to his patient, 
until her patience, and that of her friends, were exhausted — they now- 
proposed a consultation. To this he did not absolutely object, but 
begged they would w T ait another hour before they should resolve, 

* The person who has charge of this case iis supposed to be ignorant of its mecha- 
nism, because he proposes another remedy for its relief than the reduction of the fore- 
head ; or reprehensibly waits, in the hope th it the powers of the uterus will effect the: 
delivery. 



CHIN DEPARTING TOO EARLY FROM THE BREAST. 217 

assuring them at the same time that it was impossible that the labour 
would last beyond that time — the hour passed away without this hope 
being realized, and the consultation was again urged, to which he re- 
luctantly consented, from a firm persuasion that it was unnecessary. 
I was now sent for, (six o'clock, P. M.) but I happened to be some 
miles in the country, and did not return until after eleven o'clock, and 
by the time I saw the patient seventeen hours had elapsed since the 
commencement of the labour, which, until now, had rarely occupied 
two. 

703. The gentleman in attendance gave the very candid statement 
related above ; with the additional declaration, that he was " at his 
wit's end." He declared he could not possibly conceive the reason 
of this very unusual delay, and begged I would examine the patient. 
This I did ; and found the case to be, the too early departure of the 
chin from the breast, as represented in the second situation of this 
presentation. I gave my opinion to the doctor ; and tried to explain 
the mode of remedying this malposition. He undertook the operation, 
under the persuasion he understood it; and I was anxious he should, 
as he was a particular friend of the family, and was just getting into 
obstetrical business. He, however, pretty quickly abandoned the side 
of his patient ; and earnestly requested I would do what was necessary. 
I had the patient properly placed, and introduced my hand under the 
head of the child; and raised it up to a sufficient height, and then 
sustained the forehead until a pain came on: the first two pains did 
not bring down the vertex as I had hoped ; owing to the very firm 
contraction of the uterus upon the body of the child ; I now directed 
the head more towards the right sacro-iliac junction, and had the sa- 
tisfaction, upon the accession of the third pain, to have the vertex 
descend properly — I withdrew my hand ; and the head was delivered 
the next pain, to the great joy of the mother; the safety of the child, 
and the astonishment of the doctor. 

704. This case was an important lesson to this gentleman ; he 
called upon me next day, and begged me to represent the presentation 
upon the machine ; this I did most cheerfully, to his great delight and 
satisfaction ; he now thoroughly comprehended its mechanism. It 
may, however, happen, that after the reduction of the head, and be- 
fore it has passed through the external parts, some sudden accident 
may complicate the labour, and oblige us to terminate the delivery 
immediately; in such cases, the forceps must be used. It is also 
possible, that one of the enumerated accidents may complicate the 
labour before the head is reduced : should this be so, it would be 
best to turn ; provided the circumstances we deem essential to its 
success be present; or unless we should be convinced there will be 
no important time lost, in attempting the reduction. Should the re- 
duction be undertaken, and it succeed, the labour maybe finished by 
the forceps, if the natural powers are not promptly sufficient. 



218 



CASES IN WHICH THE FACE PRESENTS. 



c. — Cases in which the Face Presents* 



705. The face may present at the superior strait in four different 
manners — the most common is where the forehead offers to the left, 
and the chin to the right side of the pelvis ; 2dly, is the reverse of 
this ; 3dly, the forehead answers to the symphysis of the pubis, and 
the chin to the sacrum ; the fourth is the reverse. In face presenta- 
tions the woman always finds a difficulty in delivering herself; and 
delivery can only take place, when the head is in this position, in a 
well formed pelvis. They may therefore be considered, without many 
exceptions, an essentially bad, or preternatural presentations. Some 
authors have considered them so exclusively such as to recommend 
turning wherever the face offers. f I would not be considered as 
constantly recommending this practice ; yet I am persuaded, that 
should the third or fourth of these presentations occur,! it would be 
the best practice ; especially where we could have the choice of the 
time, and the conditions. Turning is always attended with more or 
less risk to the child, however favourable the situation of the uterus 
may be for the operation, or however dexterously it may be per- 
formed ; I may say the same, however, of face presentation ; espe- 
cially in the last two ; and above all, should the pelvis be rather 
contracted or the head large ; therefore, in such cases, there is only 
a choice of evils. 

706. It will be perceived, by the reader who may be familiar with 
the divisions of this presentation by Baudelocque, that I have re- 
versed his order. There is a propriety in this ; as I hold it to be a 
good rule, to place first in the numerical arrangement, the most fre- 
quent of any given presentation — and I am persuaded, as far as I 
dare trust my own experience, that the first and second of my ar- 
rangements are vastly the most common, if not the only varieties of 
face presentations, as seen above. Madame Boivin declares, that 
neither occurred in more than twenty thousand cases. Nay, I may 
go farther, and declare, I have hitherto not met with either the third 
or fourth ; (the first and second of Baudelocque,) and, indeed, some 
doubt may be entertained whether they have ever occurred. Bau- 
delocque does not appear to speak from his own observation on this 
subject, or he would not have proposed the employment of the vec- 
tis for the reduction of the vertex, in such cases — a mode of acting, 
I believe, that can never succeed: indeed, the vectis cannot be made 

* It seems but proper, that the face presentations should be included in the order of 
the vertex; since they are but instances of the vertex disturbed. 

t Dr. Davis is the latest author that advocates indiscriminate turning 1 , in face pre- 
sentations. He directs, " When the face is discovered to present at the brim of the 
pelvis at an early period of a labour, whether before, or very soon after the escape of 
the liquor amnii, there can in my opinion/be noMoubtof the preferableness of turning, 
to all other modes of treatment." — Elem. Oper. Mid. p. 245. 

* Madame Boivin declares that there was neither of these presentations in 20,517 
cases. 



CASES IN WHICH THE FACE PRESENTS. 219 

to reduce the vertex even upon the machine ; as I have frequently 
demonstrated to my pupils. 

707. The face may readily be distinguished from any other part, 
by the eyes, the nose, the mouth, and the chin ; and its particular 
situation may be determined by this last feature, and the nose. The 
indication in these labours, if it is determined to interfere with them, 
is to bring down the vertex, and place the chin upon the breast. 
Baudelocque (System, par. 1337,) says this is effected by operating 
upon the vertex, rather than pushing up the chin — so far as my ex- 
perience will justify differing from him, I should declare that pushing 
up the whole head before we attempt to bring down the vertex, 
though the head may still be at the superior strait, is essential to suc- 
cess. And farther, that we should always press the ball of the thumb 
against the highest part of the forehead, and urge it upwards, at the 
moment that we are endeavouring to make the vertex descend. 

70S. When these labours are terminated by the natural agents of 
delivery, they are always very tedious and painful; the child's face 
comes out much swoln and frequently livid ; the eyes tumid, and the 
child itself is often born in a state of asphyxia. " The head," 
says Madame Boivin, " being turned backwards, offers a much 
larger volume than when the occiput presents. The bones of the 
face will not suffer themselves to be reduced in volume, like those of 
the vault of the cranium ; consequently, the head engages with more 
difficulty ; and if it be a first child the labour becomes long and fa- 
tiguing. The repeated contractions of the uterus, by augmenting the 
extension of the head, causes a dragging of the spinal marrow, 
compression, and the engorgement of the vessels of the neck and 
head ; the child is thus exposed to death from apoplexy : yet these 
cases are less fatal than we should at first sight imagine ; for, of 
seventy-four cases of face presentation, fifty-eight were born natu- 
rally ; of these, forty-one were born without assistance, and seven- 
teen after the occiput was made to correspond with the axis of the 
strait; fourteen required turning, and two were delivered by the 
forceps: these last two labours were complicated by convulsions. 

709. The proper moment for acting, either as regards the condi- 
tion of the uttrus, or the situation of the head, can rarely be seized, 
in the case under consideration ; for before the membranes are rup- 
tured, they cannot be easily distinguished ; and after they are, the 
mouth of the uterus is not always sufficiently relaxed to act with 
facility or advantage; and by the time it does dilate, the waters may 
have been so long drained off as to render the attempt fruitless. 

710. In the first and second presentations,* we must have the 
concurrence of the following circumstances, before we attempt the 
reduction of the head : first, the uterus must be sufficiently open to 
permit the hand to pass, with little or no difficulty ; secondly, the 

* Of the first and second presentations, the third and fourth of Baudelocque, there 
were Beventy.onc in 20,.5I7 : of the first, forty. two; of the second, twenty-nine. 



220 CASES IN WHICH THE FACE PRESENTS. 

head must not have entirely passed the superior strait ; thirdly, the 
waters must have been recently expended. If these advantages 
combine, after having the woman properly placed, a hand must be 
passed into the uterus ; and the choice of the hand is a matter of the 
first consequence to the success of the operation : the governing rule 
is simple, and easily remembered ; namely, the hand which is to the 
side on which the vertex and forehead are placed ; that is, in the 
first, the right hand must be used ; because, when before the pa- 
tient, the right hand offers to the left side of her, or the pelvis ; 
if the second be the presentation, the left hand must be employed, 
for a like reason. 

711. In the first presentation of the face, we pass the right hand 
into the uterus in such a manner as shall put the back of the fingers 
to the posterior part of the pelvis, or before the left sacro-iliac sym^ 
physis, and place them on the side of the head, while the thumb 
is pressed against the opposite side ; the head is then to be firmly 
grasped, and raised to the entrance of the superior strait. When 
the head is thus poised, the extremities of the fingers are to be 
carried over the vertex, while the thumb is moved to the centre 
of the upper part of the forehead ; the fingers are then made to 
draw the vertex downward, while the thumb tends by its pressure 
to carry the face upward, thus executing a compound action upon 
the head. All this it should be remembered, must be executed 
in the absence of pain: if we find, when pain comes on, that the 
vertex moves sufficiently downwards, and the face upwards, to give 
assurance it will now T descend, we may withdraw the hand, and 
trust the rest to the action of the uterus. But if, on the contrary, 
upon the accession of the pain, we find the face still has a ten- 
dency downwards, we may be certain that the reduction is incom- 
plete ; and we must again and again attempt it in the absence of 
pain, if it be necessary — for, under the circumstances I have 
stated, we are pretty sure of success under a well-directed ma- 
nagement.* 

712. In the second presentation, we employ the left hand, under 
the conditions I have stated for the first : and act in every respect 
as directed for that presentation. 

713. Should, however, the above stated conditions of the uterus 
not be present at the proper time, or should the head have descend- 
ed through, (or nearly through,) the superior strait, we cannot hope 
to succeed by any attempt made with the hand to reduce the ver- 
tex ; the choice of remedy will then lie between turning, and the 
vectis. We should prefer turning when the waters have not been 
too long drained off; when the pains are not either very frequent or 
severe ; and while the head is still enveloped in the uterus. 

* Whenever the waters have been evacuated some time, the operation here de- 
scribed will be embarrassed, by the uterus narrowing itself at that portion of itself 
which corresponds to the neck of the child ; and will thus prevent the reduction of 
the head. This obstacle must not be attempted to be overcome by force — it must be 
submitted to by letting the head advance with the face foremost. 



PRESENTATIONS OF THE HEAD, &C. 221 

714. The vectis maybe tried under the contrary condition of things, 
(710) by passing it up at the side of the pelvis, until it pass over the 
vertex — when it is placed we must endeavour to raise up the face 
with the other hand, and prevent the vertex rising at the same time, 
by a counteracting force exerted by the vectis ; this should be per- 
formed in the absence of pain, and continued until the face is found 
to ascend, and the vertex descend. If these manoeuvres succeed in 
getting the vertex down, we may commit the rest to nature. It may 
however, agreeably to my own experience, be practicable to turn, 
after the vectis has failed.* 

715. In the third and fourth species of face presentations, I am 
persuaded it would be losing important time to depend upon any 
other mode of operating than turning; provided, 1st, the uterus be 
sufficiently dilated; 2d. the waters but recently drained off; and 3d. 
the head still easily moveable, at the superior strait. Should these 
important conditions be absent, it would be perhaps best, (but this is 
purely speculative,) to employ the hand in such manner, as will guide 
the forehead to the side of the pelvis ; or in other words, convert it 
into a first or second presentation of my division of the face, and then 
attempt the reduction of the vertex by the vectis, or deliver by the for- 
ceps, if the pains are not sufficiently active; and here the ergot should 
be tried. 



d. Presentations of the Head, accompanied with the Hand. 

716. The head may present perfectly well as regards its own po- 
sition, yet may be accompanied by the hand — the presence of the 
hand can sometimes be detected, before the membranes have given 
way ; and when it is found in this situation, it is almost sure to ad- 
vance with the head. If the case be under management at this mo- 
ment, the presence of the hand can rarely create any embarrassment 
to the well-instructed accoucheur; he knows that, by proper manage- 
ment, it may be easily prevented from descending. When the hand 
accompanies the head, it should be prevented from descending with 
it — this, for the most part, is readily effected by placing the point of 
the fore finger between the fingers of the child, and preventing its 
farther descent, by supporting it during a pain ; and at the same time, 
directing the hand towards ^the face. When this is properly con- 
ducted, the head gets under the hand, and makes it retire within the 
cavity of the uterus. 

717. When this case is neglected, and the hand permitted to de- 
scend, it may create great inconveniences, especially in a narrow 

* Dr. Davis propose*, for the reduction of the vertex, in face presentations, a kind of 
vectis, armed frith teeth. The objections to such an instrument he has urjrcd himself; 
namely, the wound inflicted on the scalp of the child, &.C.; and they are every way 
sufficient to prohibit its use. The common vectis, ;is I have observed, when properly 
managed, in proper casts, will succeed, as I have experienced. 

20 



222 EXHAUSTION. 

pelvis ; 1st, by obliging the head to turn away from the axis of the 
superior strait, and making the shoulder present itself in its stead ; 2d. 
by accompanying the head in its descent, and preventing the latter 
from making the proper turns that it may escape from the pelvis. 

718. The first of these difficulties will be considered under the 
head of u shoulder presentations," which see; and the other will re- 
quire the aid of the forceps — it occasionally happens, that this situa- 
tion of the hand and arm creates considerable embarrassment from the 
fixed situation it gives to the head, as well as the strong and perhaps 
dangerous compression which the arm suffers ; also, from the abso- 
lute necessity there is to depart from one of the cardinal rules for the 
application of the forceps, (783,) by placing them upon the vertex and 
forehead ; as the following case will show. I was called upon by 
Dr. Brown, to visit a patient, who had been long in labour under the 
care of a midwife, in consequence of the arm being included between 
the symphysis pubis and the head ; the labour had been stationary 
several hours, as the head could not descend, though she had had fre- 
quent and severe pains, but which were becoming more and more 
feeble, notwithstanding every possible exertion of the poor woman 
herself — the arm was very much swollen, the scalp pushed down, 
while the head was completely transverse, as regards the pelvis — the 
head, in consequence of the long absence of the waters, could not be 
pushed up, therefore, turning was impracticable. After having the 
woman properly placed, I applied the forceps so as to embrace the 
vertex and forehead — a moderate force was sufficient to bring the head 
through the superior strait; this gave so much freedom to the arm, as 
to induce me to withdraw the instruments, and apply them comme il 
faut : the head was soon disengaged ; and the mother and child did 
well. 

719. It must be recollected, that the head is not the only part 
which the hand may accompany; it may present with the breech, the 
knees, or the feet : when this happens, it rarely creates any obstacle 
to delivery per se, though it may embarrass, if improperly acted upon, 
either accidentally or designedly, by an ignorant practitioner. When- 
ever the hand is perceived at the superior strait, it should be treated 
as above directed, (716,) though the attempt to retain it within the 
uterus may sometimes be unavailing, as it frequently denotes the pre- 
sence of the shoulder at the upper strait. 



Sect. XL — 11. Exhaustion. 

720. The capacity to support the toil of labour will vary in almost 
every individual, either from original stamina, or the severity of the 
process itself. Hence, the most robust women, as well as the most 
delicate, may become exhausted from the force or the long continu- 
ance of labour — the exhaustion now alluded to, is not the mere loss 
of strength in the muscular system, but a state of inertia of the uterus 



EXHAUSTION. 223 

itself. Both these conditions may combine, or they may exist sepa- 
rately, and independently; when combined, they are almost always 
accompanied with syncope ; of this, I have already treated : when they 
exist separately, our conduct must be regulated by the system which 
suffers. Should there be a mere loss of muscular strength, and the 
uterus preserve its powers, it will offer no indication as regards deli- 
very ; but should the powers of the uterus be upon the wane, or be 
entirely suspended, though the woman possess great muscular vigour, 
it should warn us not to confide too long in this general appearance 
of strength, lest the uterus itself may be subjected to casualties inde- 
pendently of temporary loss of vigour. 

721. This situation of the uterus may arise from very different 
causes, and require very different modes of treatment, first, over-dis- 
tention from an excess of the liquor amnii : when this is the case, we 
find the pains returning at rather uncertain intervals, and confined to 
the uterine globe ; very little of that bearing down sensation, which 
accompanies the healthy protrusive effort ; the membranous bag with 
the waters is not very tense during pain ; and the patient experiences 
a general restlessness and anxiety, when pain has abated, and can lie 
only on her back. In this case the loss of power is only relative, and 
though it may have all the appearance of absolute weakness, and is 
frequently mistaken for it, yet it is not truly so ; for stimulants but in- 
crease the mischief, by exciting the arterial system, and goading the 
uterine fibres to more frequent, but to more feeble efforts. The remedy 
in this case is to remove the cause ; namely, the liquor amnii, as the 
following case will show. 

1796, May 16: Mrs. , in labour with her first child, and of 

good constitution, was taken with feeble, but pretty frequent pains in 
the night, which she bore without disturbing her fajnily until the 
morning, at which time she sent for her midwife. As the pains were 
feeble, and transitory at the time of the arrival of the midwife, she 
told her, her labour was yet too weak to bring her child, and she 
would call again in the course of an hour — she did so, and found 
things pretty innch in statu quo ; she again took her leave, and did 
not return until towards the evening; and then it was in consequence 
of a summons from the patient, who had become very uneasy and 
restless ; enjoying no interval of comfort, though the pains had become 
slower. She now examined the patient, who had at this time what 
is called a plentiful show, and the os uteri was relaxed ; but as the 
pains made very little impression upon the membranes, she concluded 
this could only arise from weakness ; she accordingly, prescribed strong 
cinnamon tea, and a stimulating injection. This injection afforded 
temporary relief by discharging a large quantity of hardened faeces; 
but the pains were still weak, though recurring frequently. The patient 
became feverish, with much headach and thirst ; the midwife and the 
friends of the patient became alarmed, and I was requested to visit 
her. 

722. On my arrival, I received the above account — I waited a few 



224 EXHAUSTION. 

minutes to observe the nature of the pains, as well as to ascertain 
other particulars. I examined the uterine globe during pain, by- 
placing my hand upon it, and found it to harden but little ; the uterus 
was enormously distended ; so much so, as to have the fundus at the 
scrobiculus cordis : the pulse was quick and full ; there was also con- 
siderable headach. I examined the state of the uterus per vaginam, 
and found, as the midwife had declared, a relaxed os uteri; or at least 
a yielding one, and very little pressure upon the membranes during 
a pain. It immediately occurred to me, that this appearance of uterine 
exhaustion was only relative ; and during the next pain, I ruptured 
the membranes ; this gave issue to a prodigious quantity of water ; 
frictions were instituted upon the abdomen; in the course of half an 
hour the pains began to increase and in half an hour more, the patient 
was safely delivered, after a labour of eighteen hours, which might 
have been terminated by proper management in six. 

723. This appearance of exhaustion in the uterus may also arise 
from an engorgement of this organ : it will, like the one just mentioned, 
stimulate weakness, or want of power, as if there was positive inertia 
present — this condition may be known by the labour having come on 
kindly, but the uterine powers are found to diminish gradually; the 
os uteri disposed to dilate ; but the presenting part is not protruded 
during pain, and the pain felt over the whole abdomen. The woman 
feels a sense of suffocation, or sinking ; the pulse is hard, full, or de- 
pressed ; and the pains irregular, both in force and frequency. This 
case is only to be relieved by blood-letting; the following case, selected 
from a number of the kind, will illustrate this situation. 

1792, August 17, Mrs. , aged twenty-eight years, in labour 

with her first child : pains commenced regularly and pre".y severely, 
and continued to be so for some time; they then became desultory 
in frequency, and less in force — the midwife, before I saw her, gave 
her some stimulating drinks, which increased certain unpleasant 
feelings ; as a sense of suffocation, heat and pain over the whole of 
the abdomen, sickness at stomach &c, without augmenting the 
force or frequency of the pains. When I saw her, she was labour- 
ing under all the distressing symptoms just mentioned, together 
with a distressed pulse, frequent sighing, great uneasiness, and very 
apprehensive that her situation was dangerous; the mouth of the 
uterus was but little dilated, though quite unresisting, when an at- 
tempt was made to stretch it; its edges were thickened, but not 
tense; during pain, very little impression was made upon the child, 
and the mouth of the uterus rather contracted than opened. As 
much oppression about the prsecordia attended, together with great 
heat in the abdomen, she was ordered to lose blood. About twenty 
ounces were taken before the oppression and heat were much di- 
minished; but as these were relieved, but not removed, and as the 
pulse acquired vigour by the operation, I w 7 as induced to continue 
the bleeding until these unpleasant symptoms should subside; this 
happened upon the loss of about ten or twelve ounces more of b!ood t 



EXHAUSTION. 225 

The pains now increased so much, that in about twenty minutes 
she was safely delivered. 

724. There is another variety of this exhausted, or rather passive 
state of the uterus, which if not well understood may mislead — it is 
where labour commences with the usual precursors, such as the sub- 
siding of the abdominal tumour : the secretion of mucous ; forcing 
or bearing down pains : and every thing giving promise of a speedy 
delivery. After these favourable appearances have continued a 
longer or shorter time, the pains cease altogether, or nearly so, 
without evident cause ; and the whole labour seems to be at an en- 
tire stand. The pulse, in this case, is very little disturbed ; but a 
train of nervous symptoms supervenes; such as palpitation of the 
heart; great oppression about the prascordia, with a sense of suffo- 
cation, if the patient attempt to lie down; and a disposition to syn- 
cope, if she rise up. The os uteri is well dilated; and the mem- 
branes remain entire. 

725. This case excites much alarm ; and is not unfrequently 
treated by stimulating medicines, or liquors, by ignorant practition- 
ers to the injury of the patient. This condition of the uterus is pe- 
culiar, and requires the administration of such remedies as may 
have a specific action upon its fibres ; such as the secale cornutum ; 
and is one of the happiest cases to illustrate its powers, as the 
following case proves. 

1S24, March 14th, I was called in haste to Mrs. , whom I 

found perfectly free from pain on my arrival. I was, however, in- 
formed that her pains had been frequent, and strong, previously to 
her sending for me; indeed so much so, that they feared I would 
not arrive in time. The pain she experienced previously to my 
coming, particularly great while lying on the bed : to relieve which 
she arose and from that moment she was easy. She complained of 
a most distressing pain at the lower part of the sternum, with a 
sense of suffocation, and a palpitation of the heart. I waited half 
an hour for the return of uterine contraction, but it did not take 
place. She was requested to lie down, in hope it Avould produce 
their renewal, as they had been severe while in a horizontal posture 
— she complied ; upon examination, the os uteri was found well 
dilated, and the head occupying the lower strait; and the membranes 
entire. I ruptured the membranes and waited another half hour, 
but pain not returning, a scruple of the ergot was given; in fifteen 
minutes the pains were briskly renewed, and she was soon after 
safely delivered of a healthy child. 

72G. Exhaustion, however, may be positive; and may be occa- 
sioned by severe and long-continued exertion. In this case, the 
uterus ceases to contract, or contracts so feebly as not to advance 
the labour. When this is so, the general strength of the patient fails 
also — she becomes listless, and indisposed to exertion ; she almost 
always sleeps between the slight pain.s, if they exists, or if they do 
not. she continues in an uneasv and disturbed slumber, or until she 

20* 



226 HEMORRHAGE FROM OTHER PARTS THAN THE UTERUS* 

may be aroused by the anxiety of her friends, or by officiousness 
in offering her something to " refresh her." The skin is almost al- 
ways damp, or even sweating; the pulse frequent and small; the 
countenance pale and haggard ; and the stomach oftentimes much 
disturbed. 

727. The original cause of inertia of the uterus is very frequently 
owing to the rigidity of the os uteri, or external parts retarding the 
labour, until the uterine powers are expended, in the attempt to 
overcome it — when this happens, the relaxation so much desired 
takes place, from both general and particular weakness; but the 
woman derives no advantage from the kindly opening of the os 
uteri, or long-looked-for yielding of the external parts, as she is now 
deprived of that energy so necessary to profit by these changes. It 
is in vain to give stimulants, or waste important time in waiting for 
the restoration of uterine power — we should, however, try the ergot; 
and, should this not renew the uterine forces, we must turn, pro- 
vided the uterus is sufficiently relaxed, the membranes entire, or the 
waters but recently expended, and the head of the child still enve- 
loped in the uterus. If the head has left the uterus or occupies the 
lower strait, and is not easily moveable in the pelvis, we must use 
ihe forceps. 

728. I have been obliged, under the head of "Exhaustion," to 
give examples that were not in strict conformity with the subject in 
question; namely, where "a natural labour was complicated, and 
required manual assistance. 1 ' But they are of an important charac- 
ter, and cannot, perhaps, be classed better under any other head. 
Hitherto, so far at least as I know, every species of inertia has 
been treated in the same manner ; the distinction I have made, I 
think, deserves attention. 



Sect. XII. — 12. Hemorrhage from other parts than the Uterus. 

729. It sometimes happens, though rarely, that a bleeding of an 
exhausting kind, as from the stomach, bowels, or lungs, may oblige 
us to finish a labour artificially, that might have terminated natu- 
rally, without such an accident. When a bleeding accompanies 
labour, which, if too long continued, would exhaust the patient, 
we should inquire, first, what agency the labour has, in either its 
production or its continuance ; and, secondly, how far immediate 
delivery would contribute to arrest it. If we are satisfied upon 
these points, and conclude, that the only chance for the woman is 
delivery, we should proceed to it, without farther loss of time. 
We should turn, when the uterus is dilated or dilatable ; when 
the membranes are entire, or they have but lately given way — 
use forceps when the uterus is strongly contracting on the body 
of the child, and the waters long expended ; or when the head is 
low in the pelvis. 



RULES FOR CONDUCTING A PRETERNATURAL LABOUR. 227 



CHAPTER XVIII. 



RULES FOR CONDUCTING A PRETERNATURAL LABOUR. 

730. Under this head, I shall only consider the rules proper for 
conducting a preternatural labour, where the hand alone is sufficient 
to terminate it, or will enable the woman to deliver herself. As pre- 
ternatural presentations, strictly so called, have nothing in them be- 
fore labour to declare their nature, we cannot possibly rely upon any 
symptoms to point them out ; we must, therefore, depend solely 
upon an examination per vaginam, to satisfy ourselves of their pre- 
sence : but as we cannot always determine with sufficient certainty 
the exact position of the child, until. the membranes have given 
way, it is necessary, as a general rule, to wait until this takes place, 
before we can decide on the species of the presentation. 

731. In the accidental preternatural labour, (651, et seq.) we 
must determine upon the necessity of interference, according to 
the extent or severity of the accident which may complicate it ; and 
not exclusively by the good or bad position of the child. We, 
therefore, in such cases, regulate cur conduct almost exclusively, 
as regards delivery, by the condition of the os uteri — should it be 
unfavourable to operating from the smallness of its opening, or its 
rigidity, we must, for the time being, abandon the idea of entering 
it to turn, or to effect any other important change upon the child, as it 
would require a force that would be wholly incompatible with the safe- 
ty of the woman, or the preservation of the child. In the mean time we 
temporize in the best manner the nature of the accident which com- 
plicates, the case will permit, by prescribing the remedies the most 
proper for the moment ; or adopting such means as may best suit the 
exigency ; as bleeding, opium, injections, &c. (See chapter on the 
causes which may render a natural labour preternatural, p. 201.) 
But, on the contrary, if the os uteri offer no difficulty, we have only 
to consider the best moment to act, when we have the choice in our 
power. This choice must be governed by general, as well as parti- 
cular rules : before, however, entering upon either of these, it will 
be necessary to point out the proper position of the woman, that 
both may be the better understood. 



228 POSITION OF THE WOMAN FOR TURNING. 



Sect. I. — Position of the Woman for Turning, and the general 
Mode of Operating. 

732. When necessity obliges us to terminate a labour, either well 
or ill begun, the woman should be so placed as to give the least pos- 
sible hindrance to the manoeuvres of the accoucheur — the propriety 
of this direction is agreed upon by all ; but there exists a diversity 
of opinion what that position is. Some recommend the side ; 
others the knees, and others the back. The latter, has always ap- 
peared to me as the best that can be adopted, for either convenience 
or advantage ; I, therefore, constantly direct the woman to be placed 
upon the back, so as to give the greatest possible freedom for 
action. This position should be made as comfortable as the na- 
ture of things will permit ; I, therefore, order the bed to be made in 
the following manner : 

733. 1st. A mattress, if at hand, must be placed so as to reach to 
the very edge of the bedstead, that it may prevent the woman from 
being injured by its hardness ; 2d. The mattress must be covered with 
a folded blanket, or sheet, that it may receive no injury from the dis- 
charges ; 3d. Two chairs should be placed at a proper distance apart, 
to support the feet of the patient; 4th. The feet and knees are to be 
steadied by an attendant sitting on each chair; 5th. An old rug, 
blanket, piece of carpet, or oil-cloth, should be spread upon the floor, 
immediately below where the patient will be placed, to secure the 
floor from being soiled by the discharges ; 6th. A pot or basin should 
be at hand, that it may be placed upon the floor below the patient, to 
receive whatever may drain from her, after she is fixed upon the bed 
for delivery ; 7th. The patient must be laid upon the mattress hori- 
zontally, with her lower extremities over the edge of the bed ; so as 
to leave the perinseum and coccyx free of the margin of the bedstead ; 
8th. She should be covered, to be protected against cold, as well as 
to comply with the rules of decency — so much regards the patient. 
On the part of the operator, the following rules are to be observed ; 
1st. All parade should be especially avoided, as well as all formidable 
preparations ; the idea should never be given that the operation in 
question is one of difficulty or hazard ; 2d. If within command, he 
should put on, after he has taken off his coat, a loose bed-gown with 
large sleeves ; these he must slip up, when on the point of operating ; 
this will prevent the exposure of the bare arms, which are always un- 
sightly both to the patient and the by-standers especially after opera- 
ting; 4th. A folded sheet should be at hand, that it may be thrown 
over the lap of the operator if he sit ; but I have ever found it more 
convenient to kneel upon a pillow ; which position I would recom- 
mend ; especially if the bedstead be low ; 5th. The hand should be 
lubricated with lard or fresh butter, as well as the vagina, and exter- 
nal parts of the woman, before an attempt be made to pass the hand ; 
6th. The time of pain should be chosen to introduce the hand ; which 



POSITION OF THE WOMAN FOR TURNING. 229 

is to be made into a conical form, that it may enter, and dilate the 
vagina the more certainly and gradually ; 7th. After the hand is in 
the vagina, the absence of pain should be chosen, to pass it into the 
uterus ; 8th. The hand should be passed in the most gentle and gra- 
dual manner, that as little "pain may be given as circumstances will 
permit, as well as not to provoke untimely contractions of the uterus ; 
9th. If the hand become much cramped or fatigued, it must be with- 
drawn, that it may recover ; 10th. The operator will be much aided, 
while searching for the feet, and in bringing them down, by making the 
other hand fix the uterus, by a gentle, yet sufficiently firm pressure, 
from time to time, externally upon its fundus ; thus giving advantages 
to the hand within, that could not be procured withoutit ; 11th. A pro- 
per selection of the hand that is to enter the uterus must be made ; 
either, not being equally proper in all cases ; 12th. The hand should 
be passed immediately to that part of the uterus, where the feet are 
expected to be ; and this must be determined by the presentation, or 
situation of the child. 

734. When the operator has gained the feet, he should, 1st. Grasp 
them firmly with the hand, but should always, in doing this, place a 
finger between them, to prevent injury, from compression ; 2dly. 
When practicable, both feet should be acted upon at the same time ; 
3dly. Though sometimes practicable, nay easy occasionally, to de- 
liver by one foot, it should never be done but from downright neces- 
sity : and this can occur but rarely ;* 4thly. In bringing down the 
feet, they should be conducted in such a manner as will make the 
toes constantly look towards the abdomen of the child ; or, in other 
words, make them pass as it were over the face ; this rule is most 
important, and should never be neglected, if we have any regard for 
the safety of either mother or child ; for if infringed, the mother may 
suffer a laceration of the uterus, and the child certain death, by an 
injury done to the spinal marrow ; 5thly. Should it only be practica- 
ble to bring one foot to the entrance of the vagina, let it be secured 
by a fillet, while search is made for the other ; 6th ly. No attempt 
should be made to turn the child during a pain, lest the uterus suffer 
laceration; 7thly. But after the feet are without, every advantage 
should be taken of pain, if it exist, to facilitate the delivery ; 8thly. 
The whole act of turning should be considered as one of necessity, 
rather than of choice ; therefore, where it is proper to attempt it, it is 
I believe, always proper to finish it, and not to trust the farther de- 
livery of the child to the powers of nature, as some have recom- 
mended ; 9thly. The operation of turning should be performed slowly, 
and steadily ; especially if it be attempted in the uncontracted uterus, 

* In order that the rule, 4th, 'par. 734,) may be rigidly observed, it will be proper 
to observe, that in complying with rule 2d, it is nocessiry sometimes to draw a little 
stronger upon one of the legs of the child than the other ; the cases where this is im- 
portant, will be readily distinguished by the operator during the turning. 



230 POSITION OF THE WOMAN FOR TURNING. 

or immediately after the evacuation of the waters ;* lOthly. Difficulty 
is frequently experienced in bringing down the breech, when the feet 
are in the vagina, owing to the head sinking in part, into the superior 
strait ; when this is the case, the head should be raised, while the feet 
are drawn downward ; this is easily managed, by applying the thumb 
against the forehead of the child, and forcing it upward, while the 
fingers which are grasping the feet are made to draw them downwards ;f 
llthly. When but one foot can be seized at a time, care should be 
taken that it belong to the side which the hand has passed over ; 
otherwise a severe twist will be given to the body of the child, and 
most probably defeat the attempt to bring it down ; 12thly. The feet 
should be brought through the external parts in such manner, as will 
place the toes towards the anus of the mother ; and when the legs 
are delivered as far as the knees, they should be wrapped in a piece 
of dry cloth, and the thighs taken hold of with the same, and gently 
drawn downwards until the nates are entirely without ; the hips should 
then be taken hold of, and the abdomen drawn through, until the um- 
bilicus appears ; 13th. When the umbilicus is exposed, a loop of the 
cord should be drawn without the vulva, that it may not be injured 
by being too severely put upon the stretch ; to do this in the best 
manner, a couple of fingers should be slid along the cord two or three 
inches, and the part of the cord above the fingers should be gently 
pulled by the upper finger, while the portion of cord next to the child 
should be prevented from being stretched by pressing it, and retaining 
it, or rather pulling it towards the umbilicus by the thumb, and lower 
finger ; while the upper finger draws down a portion of it, if it be 
sufficiently loose, by stretching itself along the upper part of the 
cord: 14th. If the cord do not descend, or cannot be made to do so 
by gentle means, and if there be reason to fear it will suffer, if far- 
ther stretched, it is thought best to cut the cord ; Baudelocque says, 
without applying a ligature, but I should think it best to apply one : 
15th. When the child is freed from the restraint occasioned by the 
cord, or if none exists, and it is delivered beyond the umbilicus, it 
should be made to pass through the arch of the pubes with its spine 
looking towards, or pressing against, either the right or left leg of the 
pubes, that the head may enter the superior strait obliquely ; this 
must be done by a little turn of the body, if it does not place itself 
in this situation as we continue our tractions downward. Little diffi- 
culty is experienced in delivering the child thus far; but its progress 
is interrupted by the axilla? appearing at the vulva ; 16th. When the 
axillae appear at the os externum, the one next to the sacrum should 
be first delivered by passing a finger or two upon the point of the 

* This rule should never be violated, as the too sudden emptying of the uterus 
may occasion accidents of a serious kind; as inversion of this organ or severe hemor- 
rhage. 

t Baudelocque, par. 1802, declares this double action to be impossible, at one and 
the same time ; but I know the contrary, from frequent experience ; and have very of- 
ten demonstrated it to my pupils upon the machine. 



POSITION OF THE WOMAN FOR TURNING. 231 

shoulder, and pressing it pretty firmly downward, and then tracing 
the arm to the elbow ; this we endeavour to bend, by pressing it on 
its internal surface exactly opposite the joint, and at the same time, 
urging it downwards, and forward, towards the face of the child, 
where it will almost always disengage itself, and fall into the cavity 
of the vagina ; from whence it is easily delivered by hooking it forward 
with the point of the finger — if the child be large, or the pelvis small, 
it is best to raise up the body of the child towards the abdomen of 
the mother, before we attempt the delivery of the first arm ; if the 
pelvis be large, or the child small, this is not necessary ; 17th. The 
second arm is now to be delivered ; this is almost alw T ays more diffi- 
cult than the first, and sometimes extremely so, if the head and arm 
are both engaged in the small diameter of the superior strait ; or when 
the arm has passed behind the neck of the child : this difficulty how- 
ever, is overcome by a very simple process, which I do not remember 
to have seen recommended by any one for this purpose ; but which 
has always, in my hands, been successful — this is, when the head and 
arm are thus situated, to turn the shoulder of that arm, to that side 
of the pelvis, to which the face of the child looks, and it will instantly 
become disengaged ; it must then be brought down as directed for 
the other ; 18th. If the head should be too high to deliver the 
shoulders as directed, it should be made to descend lewer in the pel- 
vis by pulling at the body, provided, this can be done safely to the 
child ; if this cannot be done, let the arms be brought down first ; 
19th. Should the head be so low as to press the arms strongly against 
the margin of the inferior strait, it must be pushed backwards and 
upwards, that the arms may have more freedom. When the arms 
are delivered, there remains the head to be disengaged ; for the libe- 
ration of which, we must attend to the following rules : 

735. 1st. Before any attempt be made to extract the head, its 
situation should be determined by a careful examination of its posi- 
tion ; if it be at the superior strait, the face must be at one side, that 
the great diameter of the superior strait, and that of the head, may 
correspond : if it be not in this position, let it be so placed; by press- 
ing the side of the face with a couple of fingers — when thus adjusted, 
it will readily descend by a small force applied to the body, but this 
must be in the direction of the axis of the superior strait ; 2d. If the 
head be at the inferior strait, the face should be in the hollow of the 
sacrum ; if not thus situated, we must rectify the bad position by press- 
ing against the cheek, and carrying the face to that place ; or rather, 
so that the face shall lie upon the perina^um ; when thus placed, the 
great diameter of the head, and that of the lower strait, will corre- 
spond; 3d. The body of the child must now be carefully supported, 
by passing the arm beneath its body, and allowing the legs to straddle 
the arm ; while the fore, and middle fingers, are passed one on each 
side of the neck, which will not only give support, but permit a firm 
hold when tractive force is required, to deliver the head ; 4th. When 
the head is in this situation, it is almost always without the uterus; 



232 POSITION OF THE WOMAN FOR TURNING. 

we cannot expect, therefore, any aid at this time from the contractions 
of this organ — the woman must now be solicited to employ her volun- 
tary powers of bearing down, that too much force need not be em- 
ployed, by acting on the body of the child ; 5th. To co-operate with 
the exertions of the mother, we must draw the body of the child nearly 
upward, while we press with two or three fingers upon the occipital 
bone, so as to carry it downward, and disengage it from behind the 
pubes ; this last direction I consider as one of great importance — by 
attending to it I have secured a safety to the child, which would have 
been lost without it; 6th. Advantage is sometimes gained by de- 
pressing the chin, but never by acting upon it — the object in depress- 
ing the chin is to prevent its hitching in the folds of the vagina, and 
thus creating delay and difficulty. 

736. It will be readily seen, that in deliveries of this kind, the child 
must run a constant risk, whenever there is the least delay to the de- 
livery of the head : this danger arises from, 1st. The compression of 
the umbilical cord ; 2d. The compression of the head and chest ; and 
3d. From the severe extension, the neck doing mischief to the spinal 
marrow. With a view to remove these latter dangers as much as 
possible, we should never attempt to deliver the body of the child 
rapidly or by main force ; the whole of this difficult, but highly im- 
portant process, should be conducted coolly, and deliberately; making 
all our endeavours co-operate with those of the uterus — pains should 
always be waited for, though they may be far apart ; as much of the 
mischief, which constantly threatens the child, is removed by their 
forwarding it, instead of its being the effects of force applied to its 
body. Should there be no pains, we are then obliged to act without 
them ; but we should endeavour to imitate them, by permitting inter- 
vals of rest, and soliciting the efforts of the woman. 

737. In the hurry and confusion consequent upon a delivery of this 
kind, a young practitioner is apt to forget the useful caution of not 
turning the body of the child upon the head, more than the spinal 
marrow will bear ; but this important direction must not be lost sight 
of, in attempts to deliver the head by acting upon the body — I 
once saw, in the hands of a midwife, two complete turns of the body 
at the expense of the neck ; I need not mention the result of such 
ignorance. 



HEAD PRESENTATION. 233 



CHAPTER XIX. 

THE MODE OF OPERATING IN EACH PARTICULAR CASE OF HEAD PRESEN- 
TATION. 

738. Having in the preceding pages pretty fully detailed the general 
modes of conducting the operation of turning, I shall now consider 
it, and the other methods to be pursued, in each particular presenta- 
tion of the head when rendere i preternatural by some accident com- 
plicating the labour ; or where the presentation itself renders interfe- 
rence proper and necessary. 



Sect. I. — First Presentation. 

739. I have already given the characters of the different presenta- 
tions of the vertex, therefore I shall not repeat them. I must premise 
that it is very often essential to the success of the operation of turning, 
that a proper choice be made of the hand. I would wish to impress 
this truth upon the recollection of the inexperienced practitioner ; and 
as the rule is extremely simple, there is no excuse for its neglect. 
That hand should be employed, the palm of which will look towards 
the face of the child ; therefore, in the presentation under considera- 
tion, it will be the left hand. 

740. A necessity for turning existing, the woman is to be placed, 
as already directed for preternatural labours ; (732, &c.) and the left 
hand, properly prepared, must be introduced into the vagina, with the 
thumb looking towards the symphysis pubis ; the hand must be placed 
so as to grasp the head with the ringers on one side, and the thumb 
upon the other — it is then to be raised in the axis of the superior strait, 
and placed in the left iliac fossa, where it must be retained by the 
wrist and forearm, while the fingers are made to travel over the left 
side of the child, which will be towards the posterior part of the 
uterus, until they get possession of the feet — these are to be brought, 
as already directed, as far as the middle of the vagina ; when thus far, 
it frequently happens that their farther progress is arrested by the breech 
not descending ; and the breech is prevented from descending, by the 
head having slipped from the iliac fossa, where it had been placed in 
the commencement of the operation. When this is found to be the 
case, the head must be removed by the compound action of the hand 
already described ; (734, 10th,) when this is done, the breech will 
pass into the superior cavity of the pelvis, without farther difficulty ; 
and when the feet appear without the vulva, such direction should be 
given to the breech as will place the breast of the child towards the 
left sacro-iliac symphysis ; or, in other words, obliquely as regards the 

21 



234 THIRD PRESENTATION. 

superior strait ; this is effected by acting for an instant only upon the 
foot that is immediately under the pubes, and finish the delivery as 
directed. 



Sect. II. — Second Presentation. 

741. In this presentation the right is the proper hand, for the reason 
already assigned, (739 ;) it must be passed up until the head is placed 
into the right iliac fossa, as before directed for the first presentation ; 
the right side of the child must be passed over ; the feet brought down, 
and the labour finished as above. 



Sect. III. — Third Presentation. 

742. I have already remarked, that this presentation may be bad in 
itself, and render a labour either difficult, or preternatural, where the 
measurement of the pelvis is rather below the healthy standard, or the 
head excessively large ; but that it might offer no more difficulty than 
the first, or second, where there obtained a proper relation between 
the head and pelvis. 

743. Either hand is eligible in this presentation as will be readily 
perceived, by recalling to mind the rule upon this subject — should 
the circumstances accompanying the labour, (be they original, or ac- 
cidental,) oblige us to have recourse to turning, we may employ that 
hand, of which we have the greatest command. Should nothing but 
the position of the head with a slight diminution of capacity in the 
antero-posterior diameter affect the labour, we may sometimes enable 
the woman to deliver herself, by two or three fingers applied to the 
side of the head, so as to carry the vertex towards one of the acetabula 
— to the right, if we use the right hand, and to the left, if we use the 
left — when thus placed, we may commit the termination of the labour 
to the natural efforts; provided, no other circumstance complicate the 
labour. 

744. Should this mal-position of the head not be discovered in 
time, and the uterus be contracted firmly on the body of the child, the 
fingers, (as directed above,) will not be sufficient for the removal of 
the occiput from over the pubes; we must, in this case, introduce 
either hand so that the palm will look upwards in the pelvis, and then 
take hold of the head, as already directed it should be seized; raise 
it in the direction of the axis of the uterus, and when a little freed 
from the superior strait, turn the face to the side, contrary to the name 
of the hand employed ; then trust to the powers of the woman for the 
rest, provided these appear sufficiently efficient. 

745. When, from the nature of the case, we are obliged to turn, 
we carry up the head, and give it the turn just mentioned; and where 
practicable, make the shoulders take the same course ; the hand will 



SIXTH PRESENTATION. 235 

point out the side to which the face must be turned ; then finish the 
delivery, as if we had interfered with a first or second presentation. 
If we cannot change the shoulders by acting immediately upon them, 
we may give the proper turn by pulling for a little while upon the 
right leg, if the face is turned to the left side, and upon the left, if 
turned to the right side. 



Sect. IV. — Fourth and Fifth Presentations. 

746. These presentations, in consequence of the forehead coming 
under the arch of the pubes, are always more painful and tedious, 
(caeteris paribus,) than where the vertex offers to this part ; but in a 
well formed pelvis, unless some accident complicate the labour, we 
are seldom or never obliged to turn for these positions alone. Should, 
however, any circumstance render it necessary, we may turn in these 
cases, with as much facility as if they were the first and second vertex 
presentations ; and we conduct the process precisely in the same 
manner ; that is, in the fourth, the rules for turning are exactly the 
same, as has been already directed for the second presentation, and 
in the fifth it is conducted as if it were the first — it is important, in 
these cases, that the leg which offers under the pubes should be more 
acted upon than the other, that the breech may take a proper position 
in the superior strait. 



Sect. V. — Sixth Presentation. 

747. I believe it best in this presentation to turn, if the head and 
pelvis have but their ordinary relations; and most certainly so, if the 
latter is a little contracted, or the head of more than ordinary size ; 
provided we are called early, and can have the advantage of the 
opening of the membranes; or if they have been but recently dis- 
charged. If the head be small, it will come along without much diffi- 
culty ; and if but very little smaller than the pelvis, advantages might 
be derived from turning the occiput from the projection of the sacrum, 
as recommended by Baudelocque, and as one practiced by myself, 
(see 646 ;) but this presentation so rarely occurs, that almost all I can 
say upon the best mode of treating it, is derived from analogy and 
reasoning. After the head has passed the superior strait, it can offer 
no greater difficulties than the fourth or fifth presentation ; but like 
these, it may require the application of the forceps ; for, if the waters 
be long drained off, and the uterus strongly contracted on the child, 
turning would be extremely difficult, if not impracticable ; as happened 
in the case I mentioned, (646,) having succeeded, by turning the 
occiput. 

748. When turning is attempted in this case, either hand may be 
employed at the option of the operator ; the head must be seized as 



236 SIXTH PRESENTATION. 

directed for the third presentation, and converted into the fourth or 
fifth. Baudeloc^ue recommends its being reduced to the first or se- 
cond ; I sincerely believe this to be impracticable ; I am certain it 
cannot be done if the waters have been long evacuated ; and if it have 
succeeded, it must be at the moment they have expended themselves, 
and while the head yet enjoyed freedom at the superior strait. The 
turning must be finished, as if the head originally presented in either 
of these positions. 

749. Having spoken of the modes of terminating preternatural la- 
bours where the hand alone was sufficient, I shall now proceed to the 
consideration of the forceps as a means, where the hand is not capable 
of performing it, or where it is not proper to employ it — for this pur- 
pose I shall commence with a general consideration of these instru- 
ments ; and afterwards point out the modes of application, in each 
particular case ; this will bring me to the third part of the work. 



PART III. 



WHERE IT IS NECESSARY TO USE INSTRUMENTS WHICH DO NOT NECES- 
SARILY INJURE THE MOTHER OR CHILD. 



CHAPTER XX. 



OF THE FORCEPS. 



750. I shall not unnecessarily consume time in tracing the history 
of these important but too frequently abused instruments ; nor point 
out the alterations which caprice or the affectation of improvement, 
have imposed upon them.* I shall merely declare my preference for 
the long French, or the Baudelocque forceps. An experience of 
many years, I think justifies this choice; the election is neither hastily 
nor heedlessly made ; I think I have duly weighed the merits of both 
the long and the short forceps, and the preponderance is in favour of 
the long. In making this choice I had no theory to support ; and, 
therefore, had no prejudices to overcome ; my sole desire was to de- 
termine which of the two would best answer the ends for which they 
are designed — trials, often repeated have led to the conclusion, that 
there is no situation of the head, which can be delivered by the short 
forceps, that cannot with at least equal certainty and facility, be re- 
lieved by the long ; but the converse of this does not obtain ; for there 
are situations of the head, which cannot be relieved by the short for- 
ceps, but to which the long aye every way competent ; this, in my 
estimation, is conclusive. See Plate XIII. 

* Dr. Blundell says, " I do not like to see an elegant pair of forceps. Let the instru- 
ment look like what it is, a formidable weapon. Arte non vi may be usefully engraved 
upon one blade, and cave perineo.on the other." There is much good sense in this 
suggestion. 

21* 



238 OF THE FORCEPS. 

751. I shall briefly state the objections, which experience has 
suggested, against the short forceps. For a number of years the 
short were the only forceps I employed ; and I only abandoned them 
from a conviction of their inferiority to the long. First, they can 
only be employed with advantage, when the head occupies the lower 
strait. Secondly, when it is required to deliver from the superior 
strait, or above it, neither their length nor their form will permit their 
application ; w T e are then obliged to use the long ; but the converse 
of this never happens:* Thirdly, from the shape and shortness of their 
handles, they become very inconvenient to the operator ; forbidding, 
from these causes, the application of a sufficient force to overcome the 
resistance. Fourthly, their mode of union is such as to render them 
extremely inconvenient to the operator, and oftentimes very painful 
to the patient, by including, while locking, either a portion of the 
soft parts, or some of the capilli of the pudendum, thus creating a 
great deal of pain. 

752. It is however insisted, that the last objection can always be 
removed, by carefully passing the finger around the lock; but this is 
a mistake, for it is in the act of locking that this inclusion takes place. 
Now, it is certain, that the locking of the instruments requires the 
use of both hands; consequently, we cannot pass a finger round the 
locking portion, so as to extricate the soft parts, or capilli, if included, 
or prevent theni from insinuating themselves between the joint ; as 
the hands, and, of course, the fingers, are otherwise employed at this 
moment. It is true, we may search for the included part, or parts, 
before we commence extracting ; but to relieve the soft parts would 
require the separation of the blades to a certain extent, and this with- 
out any security that it will not happen again, when the handles are 
again pressed together ; and the capilli can only be relieved with 
certainty by breaking them, which would be painful, or by cutting 
them, which is not altogether decent. The accoucheur when he aids 
with the forceps corame il faut, never receives from the public the 
praises he is entitled to, whilst the surgeon in a common operation, 
which requires no uncommon knowledge or skill, will be lauded by 
every body. 

The reason is obvious; the employment of the forceps is in a de- 
gree concealed, and not being known but by the result; whereas of 
the surgeon's effort every body can form an opinion. But the diffi- 
culties which attend the application of the forceps can only be known 
by the one about to employ them. I will assert without the fear of 

* Dr. Davis seems to entertain similar notions of the insufficiency of the short 
forceps in certain cases, and I shall avail myself of his observations on this point. He 
says, " What I wish at present to insist on, is the absolute unsuitableness of the in- 
strument known in this country by the name of the short or common forceps, for the 
relief of cases of impaction, from a disproportionate size of the foetal head within the 
pelvis, on account of a general deficiency of space within its cavity." — Elem. Oper. 
Med. p. 141. 



RULES WHICH REGARD THE POSITION OF THE WOMAN. 239 

contradiction, that there is no operation in the wide range of surgery, 
that is as difficult as the application of the forceps. 

753. In favour of the long, I may state, that no one of these ob- 
jections attaches to them ; they can be used in any position, or dis- 
tance of the head within the pelvis ; that the form and length of their 
handles give great and decided advantage to the operator, rendering 
his exertions more effective, and much less fatiguing ; their mode of 
union obviates the very serious objection urged against the short, 
(751,) for they lock without the vulva, even when the head is high, 
and remote from it, in lower positions ; besides, they unite in them- 
selves the forceps, the lever, and the blunt hook. 



Sect. I. — General Rules for the Use of the Forceps. 

754. We may divide the general rules for the use of the for- 
ceps into, a. Those which regard the position of the woman ; b. 
Those which respect the uterus and soft parts ; c. Those which refer 
to ihe application of the instruments, and their action on the child's 
head : and d. The mode, of acting, after they are applied. 



a. — Those which Regard the Position of the Woman. 

lob. Position is every way important to the successful application 
of the forceps ; but as regards the particular situation of the woman, 
there is a diversity of opinion between the British and Continental 
practitioners — and indeed, the same may be said of the different ac- 
coucheurs in our own country; this depends very much upon the 
school in which they have been educated, or the authority they are 
in the habit of following. The British practitioner almost invariably 
directs the patient to be placed upon her side, with her hips near the 
edge of the bed ;" (Denman, &c.) while the Continental accoucheur 
has her placed upon her back. (See Baudelocque, &c.) It is per- 
haps, not very difficult to explain the cause of this difference — the 
British practitioner never, or but very rarely since the days of the 
well-instructed and judicious Smellie, attempts to deliver the head 
from the superior strait, while many of the Continental accoucheurs 
do. In the first, the lateral position of the woman is, perhaps, as 
proper as any ; but, in the second, it would be impossible to deliver 
from the superior strait: now, as the position of the back enables 
the practitioner to deliver from any part of the pelvis, it should al- 
ways, I think, be preferred ; especially as the relative situations of 
the bead and pelvis will be better understood by the young practi- 
tioner — for he will have the symphysis pubis as a mark, by which 
he can determine every other part of the pelvis ; this he cannot so 
exactly do, when the patient Ls on her side. 



240 THE CONDITION OF THE UTERUS AND SOFT PARTS. 

756. Therefore, when practicable, I would recommend she should 
be placed upon her back, as directed for turning (733, &c.) both 
for convenience and safety. I say when practicable ; for it is not 
always so ; since, in cases of extreme exhaustion, or flooding, of 
convulsions, &c, we sometimes cannot move the patient to be thus 
placed ; but we can always turn her upon her side ; or if the head 
be very low, and the patient is on her back when interference is ne- 
cessary, she may remain so ; but when we can command position, I 
repeat, I prefer placing the woman upon her back, with her peri- 
neum free over the edge of the bed. 

757. Before we proceed to the use of the instruments, we should 
apprize the friends and the patient of their necessity. It rarely hap- 
pens that the patient is alarmed at this alternative, as a very short 
explanation of the mode of action of the forceps always satisfies her : 
for we have only to say, that the natural powers are insufficient ; that 
the situation of the child requires immediate relief, as its longer con- 
tinuance in the passage might be fatal. But, at the same time, we 
must not give any positive assurance of its safety by the operation ; 
though its chance should be represented as increased. Cause her to 
think the instruments an artificial pair of hands, whose use is to 
clasp the head of the child, and thus promote its delivery, and she 
becomes at once reconciled to their employment. 

758. We should take care, before we use the forceps, that the 
bladder be discharged of its urine, either by the catheter, or by a 
voluntary effort of the patient, and that the rectum be unloaded by a 
simple injection, if it has not been emptied a short time before; also, 
that the vagina, external parts, and instruments, be well lubricated 
with hog's lard, or soft pomatum, and the latter warmed by being 
placed in warm water.* 



b. — The Condition of the Uterus and Soft Parts. 



759. The forceps should never be employed, whatever may be 
the emergency, before the os uteri is sufficiently dilated, or readily 
dilatable, and the membranes ruptured. Were we to attempt their 
application before this period, we should do much mischief ; if not 
altogether be foiled in our enterprise. We must, therefore, wait 
until this has taken place ; but we should endeavour to promote this 
condition by every means which may be compatible with the exist- 
ing situation of the woman. This may sometimes be by blood-let- 
ting, as in convulsions, &c, or by laudanum, as in certain 

* In warming the forceps, care should be taken that the water is not too hot : it will 
be sufficiently warm, if the hand can just be borne in it. It is proper, even in warm 
weather, to observe the precaution of warming the forceps. 



AND MODE OF ACTION OF THE FORCEPS. 241 

kinds of exhaustion, &c., but never by force. We are told that 
the application of the belladonna to the os uteri has been useful for 
this purpose ; but of this I have no experience. Chaussier recom- 
mends the extract of the belladonna, with great confidence, in cases 
of rigidity of the os uteri. He causes it to be incorporated with some 
soft ointment, and applied by means of a particular syringe to the 
circle of the uterine orifice. In half an hour, or in forty minutes at 
farthest, after its application, he declares, the orifice of the uterus be- 
comes so much relaxed, as to offer no farther resistance to the efforts 
of the body of the fundus. — (Considerations sur les Convulsions qui 
Attaquenf, les Femmes, Encientes, p. 22* 

760. Should the membranes be entire at the time we are about to 
operate, we may very readily effect their rupture by artificial means; 
but this should not be done until the os uteri is in a proper condi- 
tion for the operation. It would be desirable, that the external parts 
should also be disposed to yield readily before we commence; 
but this is of much less importance than the relaxation of the os 
uteri ; for these may be dilated gradually by the instruments, or 
made to yield by the application of lard or soft pomatum. 



c. — Application, and Mode of Action of the Forceps. 

761. The proper application of the forceps, in each situation of 
the head, has ever been considered as an achievement of difficulty. 
It requires a complete knowledge of the various divisions of the pel- 
vis ; an acquaintance with the construction of the child's head ; and 
the mode of ascertaining its precise situation, in the cavity which 
contains it, &c. It will also be necessary to the success of the ope- 
ration, that the practitioner understands the construction and mode 
of action of his instruments, and have, by practice, acquired some 
facility in placing them. It has been considered by Dr. Denman, 
as uncertain, whether the art of midwifery has been benefited, or 
injured, by the introduction of instruments into its practice.! That 



* Since writing the above, Dr. James and myself had a case of the most rigid os 
uteri ei'her had ever witnessed. In this case we tried the bcllad. nna, without the 
slightest advantage. We, perhaps, did not apply it :is effectually as Chausier, as we 
were not in possession of his syringe for this purpose. Should another case occur in 
which I should think it advisable to employ this drus", I would introduce it by means 
of a sponge well <aturated with the extract — previously rcdu-ing its t> nacity. 

- I am convinced, that if the forceps be judiciously employed, the lives of very 
many children may be saved ; and that the death of the mother would bo a rare 
occurrence. Dr. Davis declares, " Tn my own pr.iciice, as one of the physicians to 
the Maternity Charity of London, which is beyond comparison the most extensive 
obstetric institution in Europe, I have the satisfaction of being able to assert, that I 
have never incurred the misfortune of losing a mother in consequence of a forceps 
operation." — Elem. Oper. Mid. p. 274. 



242 APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 

much mischief has been done by the ill-judged, and worse-conduct- 
ed application of the forceps, I have had reason to know ; but the 
abuse or wrong use of a thing by no means furnishes a logical con- 
clusion against its proper use. Indeed, were we to admit this rea- 
soning in almost any concern of human life, we should have a most 
reduced catalogue of real benefits ; and were it legitimate to urge 
it in the practice of physic, or surgery, we should scarcely dare to 
prescribe an article of the materia medica, or venture to employ a 
single instrument, of the very many we now consider essential to 
the exercise of these branches of medical science. Yet what prac- 
titioner would give up opium, camphor, mercury, bark, and a hun- 
dred other articles, because quacks, and ill-instructed people have 
abused them, or even destroyed with them ? or, who, in the prac- 
tice of physic, would throw aside the trephine, the scalpel, the gor- 
get, or the amputating knife, because either of these instruments in 
the hands of the unskilful might be mischievous ? 

762. Let those who are to practise midwifery, become well ac- 
quainted with its elements, before they commence it; then gradually 
proceed to the exercise of the more difficult operations connected with 
it, and the clamour against the use of forceps, will, in great measure, 
cease, because there will necessarily be less reason for complaint. A 
severe probation awaits an upright, and conscientious man, upon his 
introduction to the practice of midwifery ; for, if he be such, it will 
be a long time before he will dare to flatter himself, that he can do 
that which is best for his patient : and until he can, he will not be 
satisfied with himself — but this very distrust will, very probably, lead 
him to cultivate his talents by constant reading, that he may keep 
pace with the improvements in his profession, and seek the aid of those 
better qualified than himself, when difficulty presents itself. 

763. Much of the embarrassment, and it may be safely added, the 
risk, in the application of the forceps, might be obviated were every 
gentleman, during his medical studies, to prepare himself by the fre- 
quent application of these instruments upon the machine under all the 
various conditions the head may offer itself within the pelvis — but I 
am sorry to say, this mode of acquiring knowledge is not sufficiently 
appreciated by those to whom it would be of the most direct and 
essential service. There is a tact in every operation, which is indis- 
pensable to its well performance and success ; but this can only be 
acquired by its frequent repetition — for what would be said of the 
surgeon, who expected to acquire a knowledge of the anatomy of the 
part upon which he is about to operate by dissecting the living fibre, 
for the first time in his life ? or, who could expect a man to apply the 
forceps with skill, the first time he attempted it upon the living machine, 
without a previous exercise upon the artificial one? The same ob- 
servations will apply to turning. 

764. But it would be unfair to charge all the mischief which has 
followed the use of forceps, to the ignorance of those who have em- 



APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 243 

ployed them ; or to the action of the instrument itself — much is justly 
attributable to the views which many celebrated men have taken of 
their necessity, or utility, as well as to the rules they have laid down 
for their application. In many instances, the evils which appeared 
to follow their use really existed before they were employed ; but 
which might, I am persuaded, in many cases have been prevented, 
had a timely and judicious use been made of them. 

765. The following case, which is every way in point, occurred to 
me a short time since: A lady with her first child, felt slight pains for 
several hours before she thought it necessary to send for me. The 
pains when I first saw her were pretty frequent, but not very protru- 
sive ; the external parts rather rigid, the os uteri not fully dilated, and 
the membranes were entire. After waiting two hours, the pains be- 
came more effective, and the head soon occupied the lower strait — 
two hours more were given, at the end of which time the vertex was 
about to emerge under the arch of the pubes, and the perineal tumour 
was formed. The pains now became more distant and less forcing; 
while the external parts remained rather rigid, but not obstinately so. 
The ergot was now given at three several times, but without producing 
the slightest increase of energy in the contractions of the uterus. I 
now proposed the forceps ; — but their employment was obstinately 
resisted ; and as no advantage whatever was derived from the delay, 
and as the perinasum was very much, and permanently distended, I 
became uneasy, and represented as forcibly as I knew how, the ne- 
cessity of immediate delivery, by the forceps. I presented for the 
consideration of the patient, the advantages of immediate delivery, 
and the probable consequences to both her child and herself, if it were 
not complied with ; but nothing could prevail upon her to submit ; 
she however promised, that if she were not better in another hour, she 
would comply with my wishes. This hour, like the six preceding, 
passed away without the hoped for advantage. She now T consented 
to submit to any thing I judged proper for her relief. But I thought 
it proper, before I applied the forceps, to state to the friends my fears, 
that serious consequences might follow from this long and unavailing 
delay, though the delivery could be easily accomplished. I applied 
the instruments ; and in less than fifteen minutes she was delivered, 
contrary to expectation, of a living child ; and also, contrary to ex- 
pectation, the patient appeared to be very well, except that the catheter 
was employed two or three times for emptying the bladder. On the 
third day the urine was discharged by voluntary efforts, and every 
thing seemed to promise well, except a burning and benumbing pain 
that was felt at the extremity of the coccyx and perineum: this in- 
creased so much as to require anodynes and warm poultices. About 
the eighth day, sloughing of the perina3um commenced, and proceeded 
down to the sphincter ani, and some distance up the vagina. The 
parts have healed, however, more fortunately than could at first have 
been expected ; the perinaeum almost alone having suffered ; leaving 



244 APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 

the rectum safe, and the vagina without serious injury — the case now 
resembles a lacerated perinseum.* 

766. Dr. Denman, more perhaps than any other man, is charge- 
able with perpetuating errors in the use of the forceps, because he is 
considered the highest British authority upon the subject. In his at- 
tempt at precision, he has created confusion ; and, in his desire 
to generalize, he has made so many exceptions, that his Aphorisms 
are no longer rules. The necessity for using the forceps he has 
taken principally from the time the head has tarried at the lower 
strait or passage, and the condition of the woman ; without the 
slightest regard to circumstances which may complicate the labour 
or make a departure from the rule necessary to both mother and 
child. His aversion to instruments made him restrict their powers 
to such narrow limits, as to render them scarcely subservient to the 
art ; and he reduced the cases proper for their application to so few, 
and so peculiar, that they are scarcely to be met with, that the for- 
ceps may be employed. 

767. Thus, we find that Dr. Denman's fourth Aphorism declares 
that " the intention in the use of forceps is, to preserve the lives of 
both mother and child :" thus far good ; yet in the very next sen- 
tence he says, " but the necessity of using them must be decided by 
the circumstances of the mother only ; that is, as I understand it, 
and as I believe every body else means, we are not to deliver with 
a view to save the child, unless something threaten the mother. Is 
not this sadly and improperly limiting the utility of the forceps ? for 
what security have we, when danger assails the mother, that the 
child will not perish before we are justified in delivering it, agree- 
ably to the opinion of Dr. D. ? Let us again suppose that the body 
of the child is delivered and that the head ' cannot be made to 
pass, either from the want of ordinary power on the part of the 
mother, or from the extraordinary size of the child's head as re- 
gards the pelvis ; are we to permit the child to perish because 
there is no " circumstance," that is, as I understand it, no danger 
threatening the mother, to authorize immediate delivery by the 
forceps, though he just expressly declared their " intention" is to 
save the lives of both ? 

768. His fifth Aphorism declares, " it is meant when the forceps 
are used to supply with them the insufficiency, or the want of 
pains;" here is a plain and positive direction, one that the com- 
mon sense of mankind would at once agree to be sound and proper, one 
that would justify, in the absence of sufficient or efficient pains, the em- 
ployment of forceps to supply the deficiency of the natural powers ; 
but all this prudent and well tested direction is destroyed by the 
next member of the Aphorism; namely, " but so long as the pains 
continue, we have reason to hope they will produce their effect, and 
shall be justified in waiting." 

* I have delivered this lady safely twice since the above case occurred. 



APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 245 

769. In the Lond. Med. and Phys. Jour. Aug. 1825, p. 157, I 
am indirectly charged with misquoting IJr. D.'s fifth Aphorism, which 
I take this opportunity to disclaim. I quoted from an American re- 
publication of the Aphorisms, and agreeably to that I find I am cor- 
rect. My observations on these Aphorisms were made more than 
twenty years ago ; and if there be a discrepancy in the two texts, it 
may have arisen from a subsequent change in Dr. D.'s opinion on 
this subject ; as the reviewer quotes from the sixth edition.* The 
additional sentence, " with any degree of vigour ," alters the matter, 
little or none, in my opinion — " for with any degree of vigour," is 
extremely indefinite ; for the degree of suffering may lead to the belief 
that force is always commensurate with pain ; than which there can 
be but few greater mistakes ; especially in cases like those under 
consideration. For the cases in which the most suffering is endured, 
are often those in which we find labours the slowest. Had the sen- 
tence read, " so long as the natural pains continue with vigour," the 
meaning would have been clear ; and it would have authorized the 
alternative of the forceps, when this was no! the case. As it stands, 
even in the reviewer's quotation, I am persuaded, every ex- 
perienced practitioner would feel himself justified in waiting too 
long. 

770. I must still insist, that if this Aphorism have any meaning 
collectively, it forbids the use of the forceps so long as there are pains, 
however feeble or transitory these may be, or however insufficient for 
the end proposed — the value of pains must be estimated by their power 
upon the body to be moved, and not by the degree of suffering the 
woman may endure. But let it be recollected, that beside the risk 
the child runs by long delay in passage, the soft parts of the mother 
are suffering from the long pressure of its head ; subjecting them to 
contusion, inflammation, sloughing, &c, and this to comply with a 
prejudice against the proper employment of the forceps! But let us 
attend to what Dr. Merriman, one of the most zealous admirers of Dr. 
Denman, says upon this subject. He was called to the aid of a mid- 
wife in a case where "the vertex was actually protruding through the 
os externum," but where it was necessary to draw off the urine, as 
the woman had passed none for many hours — this was done, but he 
says, " On passing my finger into the vagina, the vagina felt so ex- 
cessively hot and burning, as convinced me that the delivery ought 
not to be trusted to the efforts of nature, but that the child must be 
removed with all proper expedition, or otherwise, there teas great 
reason to apprehend that mortification and sloughing of the vagina would 
ensue.'''' He accordingly delivered her with the forceps. His conduct 
upon this occasion, leads him to the following reflection : " It is laid 
down as a rule in practice, and it is one of those rules which, being 
founded in reason and experience, ought not lightly to be deviated 

* On consulting the works of Dr. D. as edited by Dr. Francis, I find the Aphorism 
precisely as I have quoted it ; and Dr. F. declares, he has published from the iaft edi- 
tion corrected by the author. 

22 



246 APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 

from, that the head of the child should be in a situation capable of 
being delivered by the forceps for at least six hours before they are had 
recourse to." " But a rigid observance of it in the case I have related, 
would have proved highly injurious, if not fatal, to the patient, as it 
is apparent, that a very high degree of inflammation in the vagina, and 
parts adjacent, was just upon the point of taking place ; and had the 
head of the child been suffered to remain there much longer, so much 
inflammation would necessarily come on, as might have proved in- 
controllable." In this case the head was " down low in the pelvis " 
only two hours. (Edinb. Med. and Phys. Jour, for 1810.) 

771. Dr. Davis also relates a case completely illustrative of the 
point I have attempted to enforce ; namely, that the soft parts of the 
mother may, by the long delay of the child's head in the passage, 
suffer extensive, and irremediable mischief. In the case alluded to, 
the patient was eighteen hours in labour; and, " during no stage of 
this labour, could it be truly asserted, that there was not some progress 
made." The child " effected its transit through the pelvis, certainly 
in the midst of such a tempest of struggles, as I think I have never 
witnessed on any other occasion." 

772. " The patient died on the tenth day after delivery." iC On 
inspecting the body after death," " the cause of it was discovered to 
have been a large abscess, which seemed to have implicated all the 
structures at the superior part of the cavity, and towards the left side 
of the pelvis, and of which the left ovarium, probably dangerously 
contused during labour, had all the appearance of being the nucleus." 
(Elem. Oper. Mid. p. 149.) 

773. I may also add, that the head of the child itself suffers very 
severely from a long-continued pressure upon it ; producing extensive 
extravasations under the scalp, as well as sometimes abscess of this 
part, as is said to have happened to a child that was delivered at the 
Royal Maternity Charity, after an unusually tedious and painful 
labour. Baudelocque gives an instance of the scalp sloughing, &c. 
Vol. III. p. 161. 

774. In a word, experience satisfactorily proves, that much risk, 
both to mother and child, is constantly incurred, by the head resting 
too long upon the lining of the pelvis. Dr. Davis mentions a case, p. 
(156,) where, after a labour of this kind, " the parietes of the vagina" 
were much swelled, and required blood-letting and leeching to sub- 
due it. 

775. It is merely intended, by what is just said, to justify the as- 
sertions I have made against Dr. Denman's reluctance to employ the 
forceps, and not a critique upon his Aphorisms — I have offered this 
elsewhere. See " Essays on various Subjects connected with Mid- 
wifery," by the Author. 

776. Dr. Osborn (Essays, p. 45,) carries this reluctance still far- 
ther ; to a degree, indeed, I think reprehensible, as it seems to militate 
against the interests of society — but he has not done equal mischief 
with Dr. Denman ; because his authority was not equal. He requires, 



APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 247 

before the forceps are applied, that " the powers of life be exhausted ; 
all capacity for farther exertion to be at an end ; and that the mind 
be as much depressed as the body ; and would at length both sink 
together under the influence of such continued but unavailing struggles, 
unless rescued by means of art." 

777. I would ask with what prospect of success could art interfere 
under such a complication of evils? the woman might be delivered, 
but what would be her after condition, or that of the child? — why, one 
would be subjected to all the evils which a too long delayed delivery 
would produce, if not death ; and the other, to almost inevitable de- 
struction. 

77S. Besides, the objections against the forceps are founded upon 
an erroneous estimate of their tendency— that they have been misused 
I admit; and so has almost every thing else ; but that they have been 
productive of more good than evil, I am every way persuaded. As 
regards the child, there can be no hesitation ; and as they may have 
d the mother I am certain they have been highly beneficial. It 
is entirely within my recollection, when cases similar to those now 
treated by the forceps were relieved by the crotchet — the child a certain 
victim, and the mother a probable one. In the year 1794, 1 was sent for 
by a midwife, to a woman who had been six and thirty hours in severe 
labour with her first child ; and she nearly forty years of age. Upon 
examination the posterior fontanelle was found at the left foramen 
ovale ; the pains had been violent and frequent, but were now feeble 
and transitory, making no impression upon the child. I introduced 
the catheter, and discharged a large quantity of water; then applied 
the forceps, and soon delivered the child. So soon as it was born, 
it began to cry : and when liberated from the placenta, I handed it 
to the midwife, who received it with averted face and streaming eyes. 
I inquired of her what had so affected her ; she answered by pointing 
to the child, and saying, " who with any feeling could help it? a poor 
child to be alive with its head open !" As I did not understand her, 
I desired she would explain herself; this she did, by saying she 
would not have cared so much had it been killed outright ; but to be 
wounded and alive was truly shocking!" I still insisted upon farther 
explanation, as I yet did not understand her, and at the same time 
uncovering the child, asked if she supposed it was hurt, and if she 
did she was much mistaken. She now examined the child; and to 
her utter astonishment found it without blemish. She then told me, 
she would have sent for me long before, but for the horror she had 
of having the child's head opened ; which, she assured me, had been 
the uniform practice upon such occasions, whenever she had sent for 
a physician. The influence of this case upon many of the inidwives 
of this city, procured me many opportunities of applying the forceps.* 

* Wc are not alone in making a charge against such practitioners as substitute the 
crotchet for the forceps, and with similar results from the mutilation. Mr. Dense states 
an instance, " where the child was miserably dragged alive into the world, with a 
great part of brain evacuated." And Dr. Rcatty adds, " I can never forget a scene of 



2:48 APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 

779. However strongly I may be impressed with the utility of the 
forceps, I should not feel myself warranted to use them as often as 
they appear to be in Great Britain, and on the continent of Europe. 
The frequency with which they have been employed in some instances 
is really alarming ; and I had like to have said must have been too 
often unnecessary.* In my own proper practice, I am persuaded I 
have not employed them oftener than once in three hundred and 
fifty cases ; though I have been under the necessity of using them 
very frequently in the practice of others. 

780. I must not, however, be understood as reflecting upon any 
individual, by the last remark — my meaning will be properly under- 
stood, when I state that some years ago, the practice of midwifery 
was very much in the hands of females. These females were not com- 
petent to the use of instruments ; consequently, when they were ne- 

horror to which I was a witness in the year 1800. I was called upon to see a very 
young- lady, in labour of her first child, who was under the care of one of the oldest and 
most eminent practitioners in this city, (since dead :) her labour was most violent, 
which she bore with great impatience and noise. The head had been down in the 
perineum (he said) several hours; I proposed to give more time and an opiate, not 
doubting the powers of nature, or to try the forceps, which he declined on account of 
its being her first child, and the apprehension he entertained of her being exhausted ; 
and, finally, he opened the head. The operation, as it always does, excited extraordi- 
nary uterine action, and before it- was; well concluded, or the brain evacuated, so as to 
lessen the bulk of the head, the child was propelled into the world alive and crying. 
The old gentleman, whose patient she was, was a person of very fine feelings, and the 
reader may imagine his sufferings on viewing the effects of a rash and ill-judged ope- 
ration ; he declared no earthly consideration should ever induce him again to witness 
the application-, of the perforator." 

Dr. Beatty also remarks, "that similar instances had (he had understood) occurred 
in this city, (Dublin,) in one of which humanity prompted the accoucheur to plunge 
the child into a vessel of water to put an end to its existence and cries. — Observations 
on the use of instruments, in cases of difficult parturition and protracted labour. By 
John Beatty, M. D., &c. (Dublin Med. Trans, from Johnson's Medico-Chirur. Review, 
for July, 1831.) 

* The following statements upon the subject in question, I extract from Dr. Davis's 
"Elements of Operative Midwifery." 

"It has been. stated by Prof. Baer, (see Medicina Obstetrica, p. 443,) that the for- 
ceps have been used in the practice of an individual, or of individuals, whom, how- 
ever, he has not chosen to name, in nearly one case out of every three labours. Prof. 
Kagen, of Berlin^ delivered 39 women out of 350, or 1 in 9, with forceps. Prof. N&- 
gele, of Heidelburg,, reports, that in the practice of the lying-in institution of that 
city, for the years 1817 and 1818, he used the forceps once in 53 cases. Mr. Burns 
gives the proportion of Prof. Nagele, as very much corresponding with those of his 
own lists." In a statement of presentations at La Maison d'Accouchements, between 
December, 1799, and May, 1809, furnished by the late M. Baudelocque, we have the 
proportion of forceps to the whole number of labours, as 1 in 353. Madame Boivin, 1 
in 212. Madame Lachapelle, 1 in 166. At the obstetric School of Gottingen 1 to be- 
tween 18 and 19. At the University of Stockholm, 1 in every 100. Dr. Luders, 1 in 
1 09. M. Lobstcin, 20 timea in 712 cases. Prof. Boer; of Vienna, once in 238 labours. 

In Dr. Clarke's. Abstract of the Dublin Lying-in. Hospital registry, it is stated that 
the forceps were used 14 times in 1 0,38T cases. 

Dr. Davis considers the proportion of 1 in 53, which ia approved by Prof. Burns, at 
least 400 per cent, too great; and is of opinion that the forceps are not required more 
than once in 300, or, at most, 250 cases. 

From the above statements it evidently appears, that the forceps in the hands of 
some practitioners, have been most wantonly used, and in those of some others as im- 
properly withheld., 



APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 249 

cessary, others had to perform this duty for them ; it fell to my lot to 
do much of this business. By this means I have seen very many 
forceps cases, but the greater part of these did not belong to me as 
original cases. 

781. But let me ask, what is to be feared from a proper applica- 
tion of the forceps ? is their mode of action, when well directed, such 
as to do injury to either mother or child ? certainly not — then there 
is nothing to be apprehended from their structure, application, and 
mode of action ; since necessarily, they neither cut nor contuse 
mother or child ; neither do they create unnecessary pain, nor inor- 
dinately augment that which may be present ; but are truly calculated, 
in the language of Dr. Denman, to supply the insufficiency, or want 
of labour-pains ; if this be so, and it is so admitted by Dr. D. him- 
self, why should they be condemned, because they may, like every 
sublunary good, be abused? 

782. Let me endeavour to strengthen my case, by considering, 
1st, their structure ; 2dly, their application ; and 3dly, their mode of 
action. 

783. Their structure is such as to offer the greatest possible se- 
curity to the child — the breadth of the claims being so great,* as to 
prevent any partial or injurious pressure, and the excavated diameter 
between the blades, even when the handles are pressed pretty 
closely, will permit the transversal diameter of the head of a child of 
ordinary size to lie between them, without any or with very little in- 
convenience ; the length and the strength of their handles are such as 
to permit compression wherever that compression may be neces- 
sary. 

784. The proper application of the forceps consists in their com- 
plete adaptation to the sides of the head of the child, or as nearly as 
may be over its ears — when fixed upon any other part of the head, 
it is but an exception. When placed as just suggested, the head is 
embraced in the direction of its oblique diameter, (82,) and the small 
diameter presents itself between the blades of the instrument. The 
advantages of this position of the forceps, are, 1st. That the head is 
seized in its smallest diameter; and this diameter is so little increased 
by the thickness of the instrument, as to offer no additional difliculty 
to the delivery. Indeed, it may be justly doubted, if the forceps in- 
crease the diameter in the least, as their thickness is lost by the 
yielding of the head of the child ; for compression to a certain extent 
must always be made during the operation of the instrument, and the 
united thickness of both blades does not exceed four or five lines. 
2dlv. When the head requires to be compressed, the compression 
will be in the direction of the short diameter of the head, and will 
oblige the vertex to extend itself, (however little,) in the direction 

* Dr. Dnvi?, 'Elem. Opcr. Mid.) thinks the breadth of the Frcneh forceps is too 
narrow, and proposes those of much greater breadth. I have never found any in- 
convenience in the use of these instruments, which was exclusively chargeable to this 
circumstance. 

22* 



250 APPLICATION, AND MODE OF ACTION OF THE FORCEPS. 

of the oblique diameter; as its construction gives a tendency to that 
direction. 

785. The proper application of the forceps farther consists in such 
a direction of its blades, as will permit their concave edges to come 
under the arch of the pubes, at the last period of labour — this rule is 
never to be violated; They must be placed exactly parallel upon the 
sides of the head, that they may lock ; and it is certain that they 'are 
well placed, by their locking without the necessity of force. Should 
they not lock spontaneously, if we may use the expression, force must 
not be used to make them- — for if it be employed for this purpose, 
it must necessarily be at the expense of the bones of the head, and, 
perhaps, the destruction of the child. If the handles do not readily 
join upon the introduction of- the second blade, we may be certain 
one of them has a wrong direction ; it must be ascertained which, 
and, by a judicious management of the one in fault, make it join, 
without force, its fellow.* 

786. When the. handles join kindly, we may be certain the blades 
are properly applied ; and one of the greatest difficulties of the for- 
ceps is overcome.! The degrees of compression to be applied must 
be determined by the size of the child's head ; its suppleness, and the 
capacity of the pelvis — the less compression the head requires, the 
easier, and the more successful will bethe operation. 

787. The forceps have two modes of action; a. That of com- 
pression in the first instance ; b. and, that of traction and compression, 
in the second. 



a. — Of Compression. 

788. I have already stated, that when the forceps are well applied \ 
they traverse the head in the direction of its oblique diameter or nearly 
so ; and that the compression which it may suffer, is in the direction 
of its small diameter: now, as we cannot determine a priori, the 
size of the head, the firmness of its bones, nor the resistance it will 
meet with in its passage, we cannot possibly calculate the force that 
will be necessary to reduce the head sufficiently to permit it to pass 
through the pelvis : I can, therefore, only say, the less force it is ne- 
cessary to exert, the less the head will suffer ; and consequently, so 
far as this operation is directly concerned, the greater the chance will 
be of preserving the life of the child^-and also, that the converse of 

* Nothing more clearly points out the importance of an entire knowledge of the 
mechanism of labour ; and the great necessity of learning to detect the exact position 
of the head within the pelvis by means of the sutures, than the difficulty an ignorant 
practitioner always finds in ascertaining which of the blades of the forceps is in fault 
when they do not lock. 

t We may make one exception, however, to this : namely, when the head is high in 
the pelvis, and the extremities of the forceps have only been applied upon a small por- 
tion of it: in.this case the head .is not embraced. by. these instruments ; it is only par* 
tially included, and they will consequently slip. 



OF COMPRESSION. 251 

this is equally true. Inattention to this latter fact, or a want of know- 
ledge of it, has given rise to many of the objections which are urged 
against the forceps — for it has occasioned their application upon any 
portion' of the head ; and the handles forced to lock, at the expense 
of the fracture of the skull ;* it has occasioned them to be employed 
where there was so much disparity between the diameters of the head 
of the child and the pelvis, that it could only be delivered, after the 
forceps had nearly broken down its texture : need I say what mischief 
would follow such displays of ignorance ? the child dies by a species 
of murder ; and the mother, especially in the latter instance, is sub- 
jected to inflammation, gangrene, sloughing, or even death. 

789. It has been imagined, from the elongation which the head 
sometimes permits in long-protracted labours, that it would bear with 
impunity any compressing force which might be applied ; but this is 
an error, and an error of great magnitude ; for by acting upon it, the 
benefits of the forceps have not only been under valued, but really 
called in question. I must then, to prevent the perpetuation of this 
mistake, as far as may be in my power, declare that the head will 
bear with safety but a moderate diminution of its bulk, by the com- 
pressing force of the forceps; and oftentimes, much less than is some- 
times observed to take place, when the child has been delivered solely 
by the exertion of the natural powers : the reason of this is obvious ; 
we cannot, by any contrivance of art, imitate this gradual, (though 
not always safe,) modification of the head ; consequently, when it 
becomes reduced by a suddenly applied force, like that exerted by 
the forceps, it must be at the hazard of doing much injury, or it may 
be even fatal to the child. f 

790. This fact limits the powers of the forceps more than is com- 
monly supposed^ even by those who employ them with the laudable 
hope of saving the lives of both mother and child ; but w T ho frequently 
experience disappointment, because not aware of it. The forceps, 
therefore in the hands of those who consider them as a means by which 
a difficult labour may be terminated, but who apply them without 

* I was once called upon to determine whether any thing- could be done for a newly 
born child, which had been most unskilfully delivered by the forceps. — The frontal bone 
was severely indented by the cdje of the forceps ; and one eye entirely destroyed, by 
the extremity of toe blade having hf en fixed upon it; yet it was born alive. The case 
was of course a helpless one; and the child fortunately died, in a few hours after its 
birth. I was once shown a blade of the forceps, which had been excessively bent, by 
an endeavour to m ike it lo<-k. In this case, the forceps were exhibited in triumph, as 
a proof of the great diffi ul*v the operator hnd to encounter, in effecting the delivery; 
and as additional evidence of this he declared, that no strength was suffi< icntto deliver 
the bead, as both h ; s, (and he was a powerful man,) and that of an equally ignorant 
practitioner, were unavailinndy cxeried, alternately and collectively — he at hist delivered 
with the crotchet, after having experienced very great difliculty in withdrawing the 
bent blade of the forceps. 

t Dr. Divis, ho.vever, asks, ll whether in some particular circumstances it might 
not be found more eligible to apply to the festal head a certain required amount of 
compressing force, v. ithin a short lime, artificia'ly by means of the forceps, than to 
await the result of a more gradual and protracted application of an ultimately equal 
degree of force by (.he natural agen's of parturi'ion ?" — Elcm. Oper. Mid. p. 13 J. 



252 COMPRESSION AND TRACTION. 

rule, or without a knowledge of their mode of action, are nearly as 
fatal as the crotchet itself ; because they are regardless of the degree 
of compression they impose upon the head during its extraction.* 
It would seem, then from all experience to follow, that from a pelvis 
with less than three inches, or even three inches aud a half in its 
small diameter, a child's head at full time cannot be made to pass 
with safety by means of the forceps, unless there be an unusual de- 
gree of suppleness in the bones of the cranium, or the head itself 
unusually small. If these facts were more generally known, or more 
constantly kept in view, we should have fewer complaints against the 
forceps, because there would be fewer victims to their ill-directed 
power upon the head of the child, and fewer evils following their 
application upon the soft parts of the mother. 



b. — Compression and Traction. 

791. It is in but very few cases that we can avoid a pretty constant 
compression, from the moment of their application upon the head of 
the child until its final delivery. With a view to diminish the perma- 
nency of this pressure as much as possible, I am in the habit of not 
tying the extremities of the handles, as is usually recommended, that 
I may after each tractive effort permit the instruments to expand, as 
much as the elasticity of the head, and the restricted capacity of the 
pelvis will permit. In this, I think there is decidedly an advantage 
to the child ; and no possible injury can happen from it to the mother. 



d. — Mode of Meting after Application. 

792. Each effort made to advance the head after the forceps have 
been applied, must be considered as a renewed compression, though 
the lateral pressure may be but very little increased ; for in order that 
the head may advance, the curved extremities of the instruments 
must necessarily act at nearly right angles with their sides ; conse- 
quently, the transverse diameter must be a little increased, or rather 
not so much diminished, as if the pressure were strictly and only 
lateral ; this consequently must, to a certain extent, increase the dif- 
ficulty of delivery ; or, in other words, increase the necessity of a 
stronger tractive force. This, however, is in some measure, if not 
altogether, obviated by '"making each blade of the forceps act alter- 
nately as a lever in conducting the delivery; and this is the usual 
direction given for their employment, without expressing the reason 
for it — hence, when the instruments are fixed, we act with much 

* I have more than once witnessed the truth advanced here. I have seen the whole 
length or nearly the whole length of the frontal bone cut through, by one of the sharp 
edges of the forceps, by an effort to compress it; and at another, I have seen the 
parietal bone in the same wretched plight from the same cause. 



MODE OF ACTING AFTER APPLICATION. 253 

greater effect, by drawing from blade to blade, than if we continue the 
force in a direct line ; for, by making the handles describe a portion 
of a circle, by passing them from right to left, and the reverse, during 
the traction, we each time, (when the head is moveable,) make a part 
of its sitle sink lower into the pelvis, and advance towards the exter- 
nal opening of the pelvis. 

793*. The extent of this motion of the handles must, at first, be 
very small, especially if the head be high in the pelvis ; or we shall 
be making fulcra of the soft and bony parts of the mother at each 
effort, which must always be carefully avoided. As the head ad- 
vances, we may enlarge the space through which the handles are to 
move, but it is never to be so extensive as to make the instruments 
press with much force against the bones, forming the arch of the 
pubes, and the external soft parts of the mother. 

794. The motion just spoken of is at first horizontal, or very nearly 
so, but as the head advances, we are obliged to elevate the extremities 
of the instruments, and this in proportion as it approaches the vulva, 
or as it is about to escape the external machinery ; so that at the last 
moments, the extremities of the handles are laid nearly upon the 
abdomen of the mother. During the operation, our tractive efforts 
should coincide with the action of the uterus, whenever that remains; 
where the uterus has ceased to act, we should permit as much time 
to elapse between each exertion, as generally takes place between 
the pains at this period of labour, that we may not exhaust the woman ; 
that we may secure the tonic contraction of the uterus, that we may 
not make too sudden and too long continued compression on the 
child's head. 

795. It is by no means unusual for the pains to cease after the 
application of the forceps ; and we are obliged in consequence, to 
perform the delivery without their aid — I am at a loss to account for 
this ; for it is contrary to what might reasonably be expected. When, 
however, they continue with even moderate force, I have been in 
the habit of disengaging the instruments, when the head is about to 
pass through the external parts, that these may be the better sup- 
ported, and the risk of laceration diminished. Should there be no 
pain, we are then constrained to continue our efforts, until the head 
is without. 

796. In removing the forceps before the head is delivered, I am 
aware I am departing from high authority ; for Dr. Denman lays it 
down as a rule, that " in every case in which the forceps have been 
applied, they are not to be removed before the head is extracted, 
even though we might have little or no occasion for them." But 
notwithstanding this positive injunction, I am entirely persuaded, 
from experience, it is the safer practice, if we regard the integrity of 
the soft parts of the mother worth preserving. 



254 RECAPITULATION. 



Sect. II. — Recapitulation. 

797. As I have dwelt upon the use of the forceps longer than I had 
intended, I shall sum up in a few words the principal points intended 
to be insisted on, or illustrated : 1st, That the long French forceps are 
preferable to the English short forceps, even for the unskilful ; 2d. 
The best position for the woman is that recommended for turning; 
3d. The bladder and rectum are to be emptied before the forceps are 
introduced ; the former by the catheter, when the woman cannot com- 
mand the discharge ; and the latter by an injection, if it has not been 
done spontaneously, a short time before ; 4th. The patient and friends 
are always to be apprized of the necessity and propriety of the opera- 
tion before it is resorted to ; 5th. The vagina, external parts, and the 
instruments are to be coated by fresh hog's lard, or soft pomatum, 
and the instruments always warmed ; 6th. The forceps are never to 
be employed before the os uteri and external parts are relaxed, and the 
membranes ruptured ; 7th. This relaxation to be promoted by the best 
adapted means ; 8th. Should the uterus be in a proper condition for 
the operation, and the membranes at the same time entire, the latter 
must be ruptured, that the application of the forceps need not be de- 
layed, when the case requires immediate interference ; 9th. When the 
circumstances of the case require the use of these instruments, the 
application should not be too long delayed, from an imaginary fear 
that the woman might suffer from their use, or from an ill-grounded 
hope that the woman may deliver herself— we should, therefore, not 
permit her to be exhausted, or the child to perish, because feeble or 
inefficient pains attend, or because the head of the child has not been 
six hours in the passage ; 10th. The blades of the forceps are always 
to be applied to the sides of the head — that is, over the ears of the 
child — when necessity (which is very rare,) obliges us to depart from 
this rule, it is but an exceptio-n to the rule ; 11th. They must be ap- 
plied so that their upper or concave edges, will come under the arch 
of the pubes, at the last period of labour ; 12th. Should the handles 
of the instruments not join with ease, we may be certain they are ill- 
applied ; the cause of their not locking must be ascertained; and they 
are never to be joined by force ; 13th. The head will not permit with 
safety, but a moderate approximation of its sides ; therefore, when 
compression is carried beyond this point, the destruction of the 
child is sure ; 14th. With a view to prevent all unnecessary, and too 
long continued pressure upon the head of the child, the handles of 
the forceps should not be tied ; but after each tractive effort they must 
be permitted to expand themselves, by ceasing to press upon them ; 
15th. Each traction should be made from blade to blade; that 
each may act as a lever upon the head ; 16th. The extent of 
the motion of the handles for this last purpose, must be regulated 
by the distance the head is from the external parts ; for the less the 
head is advanced, the more circumscribed should be the motion ; and 



GENERAL OBSERVATIONS UPON THE FORCEPS. 255 

the reverse — this motion is at first nearly horizontal;* 17th. The ex- 
ternal extremities of the instruments must be raised towards the ab- 
domen of the mother, in proportion as the head advances through 
the external parts ; 18th. Should pains continue until the head has 
nearly passed through the external parts, the forceps may be removed ; 
but if none attend, the delivery must be completed by the forceps. 



Sect. III. — General Observations upon the Forceps. 



79S. In delivering by means of the forceps, every attention should 
be paid to delicacy, and every care should be taken that the patient 
be not subjected to unnecessary pain ; to fulfil the first, the patient 
should not be exposed ; this cannot be necessary, even for the drawing 
offof the urine, should that be an essential previous step. The ope- 
rator must become familiar with the introduction of the instruments 
without the aid of sight, more especially as this cannot serve him, 
and must, if employed, be highly offensive to the patient. He must 
perform his duty undercover ; and the guide for his instrument must 
be the hand in which the instrument is not held — this, of course, will 
sometimes be the right, and at others the left — two or three fingers 
must be introduced so as to touch the child's head when at the lower 
strait, and the extremities of them must be insinuated under the edge 
of the os uteri, jf that is still down; and upon the plane thus formed 
by the fingers, the instruments must be conducted ; with this precau- 
tion he shall give no unnecessary pain ; since it will prevent the edge 
of the uterus from being included between the blade of the forceps 
and the head of the child. 

799. Should the head of the child have escaped from the os uteri, 
he must pass the instruments in such a manner as shall conduct their 
extremities under its edges ; this is done by keeping the point of the 
blade pretty firmly passed against the scalp of the child as it passes 
into the pelvis — should it, however, meet with any obstruction in its 
passage, the difficulty must be overcome by address, and not by force 
— it may be a fold of the scalp, or it may be the ear, by which the 
point of the instrument is arrested ; gently depressing the handle of 
the instrument, or varying its direction a little, will almost always sur- 
mount this difficulty. 

S00. Should much pain be experienced by an attempt to lock the 
blades when well applied, as regards their position, we may be pretty 
certain a portion of the neck of the uterus is included in the grasp 
of the instruments — we must inquire on which side of the pelvis the 
pain is felt and withdraw the blade from it, and introduce it anew. 
Should cramps be induced, we may sometimes relieve them by ele- 
vating or depressing the handles of the forceps. 

801. The greatest care must be taken, before we begin our traction, 

* That is, from one thigh of the mother to the other, 



256 GENERAL OBSERVATIONS UPON THE FORCEPS. 

that no portion of the mother is included in the locking of the blades 
— this must be done by passing a finger entirely round the place of 
union. This accident very rarely occurs in the use of the long forceps, 
unless the head is high in the pelvis — with the short it is frequent, 
even under the direction of the most careful operator ; this forms, 
in my estimation, a very serious objection to their employment. I 
was once called to a poor woman who had had a considerable portion 
of the internal face of the right labium removed, by having been in- 
cluded in the joint of the short forceps. 

802. When the instruments are properly adjusted, we should seize 
the hooked extremities with the right hand, and make them approach 
each other in the most gradual manner, and make no more compres- 
sion than is absolutely necessary to secure a certain hold, or to enable 
the head to pass:* the left hand must be applied over the joint of 
the instruments, and in a manner that will permit the point of the 
index finger to touch the head of the child, which will enable him 
to determine the progress it makes. We commence the traction with 
a very small force, and gradually augment it to the extent we may 
judge necessary — we should finish the effort by gradually diminishing 
the force, until it comes to a state of rest, taking care, however, to 
maintain the advantage we have gained, by removing the pressure 
from the handles, and hooking two fingers in their curved extremities, 
and thus prevent the receding of the head. When we have indulged 
the uterus in a sufficient interval, or upon the accession of a pain, we 
are to apply our hands as just directed, and act as before. 

803. As the head is about to pass through the external parts, the 
left hand must forsake the instruments, and apply itself firmly against 
the now distended perinseum ; and, if there be sufficient power in 
the uterus to carry the head through the os externum, without farther 
aid of the forceps, they should be removed as advised ; but, if not, 
they must be suffered to finish the delivery. 

804. When the head is without, the same care should be exercised 
as was recommended in a natural labour; that is, not to hurry the 
shoulders through the pelvis, that the tonic contraction may certainly 
follow their expulsion. 

805. It is frequently more convenient to stand to perform this 
operation than to sit; but a chair should be at hand, that we may use 
it after the head is delivered : we should order a sheet sufficiently 
folded, to be spread over our lap, that we may receive the child upon 
it when the body is expelled. The funis must be cut at a proper time, 
and the rest of the delivery finished as on ordinary occasions. 

* When the pelvis is deformed, and the relation between it and the head of the child 
is very strict, we are obliged to depart from this rule, and apply a much stronger com- 
pressing force ; as the diameter of the head must be a little diminished, that it may 
pass : in this instance, the handles are to be brought together, and secured by a gar- 
ter or riband. 



OF THE SPECIFIC APPLICATION OF THE FORCEPS. 



257 



CHAPTER XXI. 



OF THE SPECIFIC APPLICATION OF THE FORCEPS. 

806. Generally speaking, the difficulty of applying these instru- 
ments is in proportion to the remoteness of the head from the inferior 
strait, and the facility of application, as the vertex, or forehead, may 
be near the arch of the pubes. It would be well, were it always 
practicable, or a subject of choice, that the young practitioner should 
commence with the most simple cases, and gradually advance to the 
more difficult positions of the head ; but, as this is impossible under 
the circumstances of ordinary practice, he should, while in his power, 
become in some measure familiar with the application of the forceps, 
by diligently practising upon the machine : indeed, it would be highly 
advantageous to all who may be about to engage in obstetrical practice, 
to order a machine as an appendage to their instruments. By the 
use of this contrivance he can become well acquainted with every 
important presentation, and at the same time render himself master 
of their respective mechanisms ; he can familiarize himself to the 
application of instruments, and readily teach himself the routine of 
turning, &c. 

807. I shall lay down the rules for the application of the forceps 
in every presentation as succinctly as the subject will permit, knowing, 
from long observation, that nothing but a careful experience with the 
living subject can ever make a man adroit in their use. I shall there- 
fore, commence with the most simple cases, and gradually advance 
to the more complicated and difficult. 

808. The various ways which the head of the child may offer to 
the pelvis, when it may be necessary to terminate the labour by the 
forceps, are, 

809. a. 1st. Where the vertex answers to the arch of the pubes, 
and the forehead to the sacrum. 

810. 6. 2d. The reverse of this, the forehead to the pubes, and 
vertex to the sacrum. 

811. c. 3d. Where the vertex is behind the left foramen ovale, 
and the forehead to the right sacro-iliac symphysis. 

812. d. 4th. Where the forehead is behind the left foramen ovale, 
and the vertex to the right sacro-iliac symphysis. 

813. e. 5th. Where the vertex is behind the right foramen ovale, 
and the fore}iead to the left sacro-iliac symphysis. 

814. f. 6th. Where the forehead is behind the right foramen ovale, 
and the vertex to the left sacro-iliac symphysis. 

815. g. 7th. Where the position of the head is directly transversal : 
23 



258 OF THE SPECIFIC APPLICATION OF THE FORCEPS. 

1st. Where the vertex answers to the left side of the pelvis; and 2d, 
Where it answers to the right. 

Sect. I. — a. 1st. Application of the Forceps in the first of these Posi- 
tions. 

816. The woman about to be delivered with the forceps is con- 
stantly supposed to be placed upon her back, and every other circum- 
stance arranged as already directed. 

817. The first position in which we are to apply the forceps, Dr. 
Denraan thinks can very rarely require them — this by no means com- 
ports with my experience ; for I have very often been under the ne- 
cessity of using them in this situation of the child's head ; for any 
one of the causes which I have considered capable of complicating a 
labour, may happen at this period, as well as any other. What is 
there in this position which shall protect the woman against flooding, 
convulsions, exhaustion, &c, and render immediate interference un- 
necessary ? I can see nothing ; for, though the labour is near its com- 
pletion, it is not completed; and I am convinced, that in many cases 
both mother and child have suffered from the delay which Dr. Den- 
man's repugnance to the employment of these instruments has created 
with the practitioners, who consider him the best authority. Were 
it necessary, it would be easy to give examples to prove what I have 
just said. (See 765, 771, 772.) 

818. In this case, after duly preparing the forceps as already direct- 
ed, we take hold of the male branch of the forceps with the left hand, 
and hold it as we would a pen when writing, while we introduce two 
or three fingers of the right hand into the vagina against the child's 
head, and under the edge of the uterus if practicable ; we then hold 
the handle or blade nearly perpendicular, but inclining to the right 
side of the mother, and insinuate the extremity of the blade between 
the labia, and slide it along the fingers intended as a guide, until it 
reaches four or five inches within the pelvis ; gradually depressing 
the handle as it advances, and as it embraces the head. It rarely 
happens that any difficulty is experienced in the introduction of this 
blade ; its position, if properly applied, is strictly lateral ; its concave 
edge being under the arch of the pubes, the pivot will have a vertical 
position, while the handle will be sustained by the edge of the peri- 
nseum. The instrument must be retained in this position either by an 
assistant, or by placing it on the knee, while you prepare for the intro- 
duction of the other blade — this must be taken in the right hand, as 
directed for the other blade ; and must, like it, be conducted to its 
proper situation by two or three fingers of the left hand ; when ad- 
vanced as far within the pelvis as the first blade, the handle must be 
lowered and inclined towards the left thigh of the mother, until it 
crosses the first blade, and locks with it — if the instruments are pro- 
perly applied^ this will readily happen — the pivot w T ill be vertical, 



OF THE SPECIFIC APPLICATION OF THE FORCEPS. 259 

and must be turned, that the blades may be secured in their position 
with each other — the handles are now to be seized, and the delivery 
conducted as already directed. 



Sect. II. — b. 2d. Application in the second of these Positions. 

819. This position, (810,) is by no means as favourable for delivery 
as the first, though not more difficult for the use of the forceps ; the 
presence of the forehead under the pubes, as I have already stated, 
(633,) always renders it more difficult for the woman to deliver 
herself; and sometimes is of itself a sufficient reason for the use of the 
forceps.* The application of the forceps, is, however, precisely the 
same as in the one just described; we are only to observe, in finishing 
the labour, to permit the vertex to turn backward, as it is described 
to do when speaking of its mechanism. 



»Sect. III. — c. 3d. Application of the Forceps in the third of these 

Positions. 

820. The application of the forceps in this situation (811) of the 
head is more difficult than in the two preceding; owing to the oblique 
manner in which it oners at the lower strait. It must assume this 
position before it can ofTer its vertex to the opening of the pelvis, but 
it may fail to make this necessary change, and thus render the labour 
difficult ; or the causes which may complicate any labour may operate 
at the moment the head has arrived at the place designated, and thus 
render the use of the forceps indispensable. 

821. When the forceps are to be used, the male blade must be 
passed to the left side of the pelvis at about the same distance as be- 
fore directed ; it will almost always pass along easily, after having 
spontaneously assumed a change of position ; this change carries the 
handle a little toward the left thigh of the mother, and gives to the 
pivot an oblique position, instead of the vertical one before spoken of 
— after the first blade is adjusted, the other must be passed nearly op- 
posite to it, but a little higher, and immediately against the right leg 

^ * Mr?. S., M»y 7th, 1827, in labour with lv r second child ; the presentation was the 
fifth, but could not be reduced to the first by any effort I could make, owing to the 
Be of the child's head. After waiting unavailingly for several hours for the 
natural powers to effect the delivery, I was obliged to use the forceps. I have no 
doubt but the use of instruments would have hen unnecessary in this case, had the 
vertex presented, as the pehis was ample a< ordinary, the parts well relaxed, and the 
pains frequent and powerful. As this child was of unusual dimensions, I will subjoin 
the measurement of several parts. 

16 6-8 inches round ihe forehead and occiput. 
19 \. 7 l " round the shoulders 
5 5-8 " round the arm and below the elbow. 
The other parts of the body, proportionally large. The head of the I hild wa- length- 
ened considerably; bu' it recovered its shape in a few days. 



260 OF THE SPECIFIC APPLICATION OF THE FORCEPS. 

of the pubes, and behind the right foramen ovale ; the handle must 
be made to incline like its fellow to the left thigh: and, if properly 
conducted, the blades will lock ; but in a manner that will enable the 
pivot to preserve its look towards the left groin of the mother. 

822. When the instruments are joined, we are directed by Baude- 
locque and others, to turn the vertex towards the arch of the pubes ; 
but this is certainly not always necessary ; for I have usually found, that 
this took place spontaneously as I continued the traction. I have no 
doubt but this is occasionally necessary;* especially where the pelvis 
is rather narrow, or the head large, and when we find, after succes- 
sive efforts, the head does not follow the proper direction, we may 
turn the vertex towards the pubes, by gradually bringing the pivot to 
a vertical position — when this is done, this case is precisely like the 
first of these positions, and the labour must be finished like it. 

823. In several instances of this position, I have found it easier to 
introduce the second blade from below, pressing the handle of the first 
blade pretty firmly against the perinseum — that is, instead of having 
the handle high over the abdomen, to place it under the left thigh of 
the mother, and make the extremity of the blade penetrate from down- 
ward, upward : care must be taken not to place the female blade be- 
low the male in this case. 



Sect. IV. — d. 4th. Application of the Forceps in the fourth of these 

Positions. 

824. This position (812) unites the difficulty of the oblique situa- 
ation mentioned just now, with the disadvantage of the forehead 
under the arch of the pubes ; and, though the application of the for- 
ceps is precisely the same as in the last described position, it will 
nevertheless be a more difficult operation, for the reason just stated. 
At the last period, when the head is escaping the vertex must be suf- 
fered to turn backward, as in the second position. 



Sect. V. — e. 5th. Application of the Forceps in the fifth of these Po- 
sitions. 

825. The position (813) is of more difficult management than any 
of those I have yet described, owing to the necessity of placing the 
male branch above ; and obliging the female branch to be placed 

* Baudelocque tells us, that he has occasionally failed to establish the vertex under 
the arch of the pubes; and, in these cases, the head has passed through the inferior 
strait and external parts in a diagonal direction. I have witnessed this direction of 
the head in a number of instances, where the forceps were not employed ; but it has only 
occurred to me once, when employing these instruments — when this happens, it is 
generally owing to the sacrum being too straight. 



OF THE SPECIFIC APPLICATION OF THE FORCEPS. 261 

below — but these difficulties may be surmounted by gentleness and 
perseverance, and by a just knowledge of the position of the head. 

826. The male branch of the forceps must be conducted by the 
left hand behind the left foramen ovale ; this must be done by pass- 
ing the extremity of the blade upon two or three fingers immediately 
under the left leg of the pubes ; the handle of course must be de- 
pressed in proportion to the advancement of the blade, and made to 
incline towards the right thigh of the mother; and, when correctly 
adjusted, the pivot will take an oblique position, and look towards 
the right groin of the woman. The female blade must be introduced 
on the inferior part of the right side of the pelvis, and adjusted so as 
to correspond with the first introduced blade — the handles must then 
be locked, and seized by the left hand at the extremities of the 
blades; while the right will take hold over the pivot; a finger to 
be placed against the head of the child, as before directed. 

S27. It is not generally necessary to turn the vertex towards the 
pubes in this case, any more than when it was on the opposite side 
of the pelvis; this will take place as in the former case, by observing 
the proper direction for the tractive forces. 



Sect. XI.— f. 6th. Application of the Forceps in the sixth of these 

Positions. 

828. The relations of the head and pelvis in this case, (814,) as 
regards diameters, are precisely the same as the -one just described ; 
and the forceps must be applied in the same manner. The same 
precaution must be taken at the final passage of the head through the 
external parts, to permit it to turn backward. 



Sect. VII. — g. 7th. Application of the Forceps in the seventh of these 

Positions. 

829. Dr. Denman, in his Aphorisms, seems to acknowledge but 
one mode of applying the forceps, for the last four positions, and the 
one now under consideration, (815;) and his directions for all, are 
only applicable to the last. This position of the head must be rare; 
at least I have encountered it but once, and it was relieved by one 
blade of the forceps acting upon the vertex, so as to aid the efforts of 
the uterus, (which were very strong,) in bringing it towards the sym- 
physis pubis. 

830. When the forceps are resolved on, and the vertex of the 
child is to the left side of the pelvis, the female branch of the forceps 
must be placed behind the symphysis pubis, and the male blade be- 
fore the sacrum. The handles of the instruments should be made to 
incline towards the left side of the mother, that the vertex may de- 
scend rather more than the forehead. When the vertex is on the op- 

23* 



262 GENERAL REMARKS ON THE USE OF THE FORCEPS, &C. 

posite side, the male branch must be inserted behind the pubes, and 
the female branch before the sacrum ; the handles, in this case must 
be inclined to the right thigh of the mother, for the reason just 
stated. 



CHAPTER XXII. 



ABOVE THE SUPERIOR STRAIT. 



831. Smellie appears to be the first who had either sufficient skill 
or hardihood, to apply the forceps when the head was free above 
the superior strait, and since his time he has had but few followers.* 
This, however, has not arisen so much from the contemplation of its 
dangers, as the consciousness of its difficulties. To employ the for- 
ceps with success under such circumstances, it is necessary that the 
operator be aware of all he may have to encounter ; as well as be 
skilled in their application, in the situations we have just considered ; 
therefore, it cannot be recommended as a resource to inexperienced 
practitioners. 

832. Baudelocque's observations upon this subject are so just and 
so important, that I must recommend them to the serious considera- 
tion of every gentleman who may intend to pursue the practice of 
midwifery. Fortunately, the necessity of operating with the forceps, 
while the head is in this situation, seldom occurs, especially in this 
country, where almost the only apology for their use, namely, a nar- 
now pelvis, is of but very rare occurrence. I have been obliged to 
use them but five times in this situation of the head in more than 
forty years ;f my experience, of course, in this necessity, is very 
limited. On this account, especially, I refer to the high authority 
just mentioned, and forbear to give directions for their use. I be* 
lieve that the frequent mention of difficult, dangerous, and rare ope- 
rations, leads oftentimes to the unnecessary performance of them, not 
always so much from the necessity of the case, as the eclat which 

* Dr. Davis, (Elem, Oper. Mid.) appears to have used the forceps when the head 
was above the superior strait; and recommends it with every apparent confidence, in 
several cases where immediate delivery may be necessary. This however neither 
diminishes the difficulty, nor lessens the danger of these instruments, when awkwardly 
used. In his hands, the forceps may relieve the head from any situation in which 
it may be placed ; but it must be recollected that few can boast of his experience or 
adroitness. 

t It is a little remarkable, that I was under the necessity, lately, of using the 
forceps twice within ten days of each, other,, when the head was at the. superior 
strait. 



OF THE LOCKED OR IMPACTED HEAD. 263 

attends them, however unsuccessful. In surgery, I have known it to 
happen more than once ; and once certainly, in widwifery. 

833. When necessity obliges us to deliver when the head is 
situated at the superior strait, it is much better to have recourse to 
the doubtful but safer alternative of turning — for it will rarely happen 
that this cannot be performed while the head remains free above the 
superior strait, even where the pelvis may be a little contracted, 
with at least as much safety to the child, and certainly more to the 
mother.* I should therefore earnestly recommend to every un- 
skilled practitioner, not to attempt this difficult, nay, in such hands, 
dangerous operation. Even Smellief himself, the original projector 
of the use of the forceps at the superior strait, deprecates their employ- 
ment at this part of the pelvis : he says, <c a long pair of forceps may 
take such firm hold, that, with great force, and the strong purchase, 
the head may be delivered, (from the superior strait,) but such vio- 
lence is commonly fatal to the woman, by causing such an inflamma- 
tion, and perhaps laceration of the parts, as is attended with mortifi- 
cation. In order," continues he, " to disable young practitioners from 
running such risks, and to free myself from the temptation of using 
too great force, I have always used and recommended the forceps so 
short in the handles, that they cannot be used with such violence as 
will endanger the woman^s life." From this it would appear, that 
even in the hands of one of the most expert accoucheurs that ever 
lived, there was much danger attending delivery by the forceps while 
the head remained at the superior strait. 



CHAPTER XXIII. 



OF THE LOCKED OR IMPACTED HEAD. 

834. When the head has advanced some distance into the pelvis,, 
and cannot proceed farther, and when it is immoveable, except up- 
ward in the pelvic cavity, it is then said to be locked or impacted. 

* Dr. Davis proposes to deliver from the superior strait, under circumstances not 
recognised by any other practitioner. He observes, " In profuse uterine hemorrhage, 
for instance; the orifice of the uterus being supposed to be amply dilated, but the head 
of the child still at the brim of the pelvis, this method of treatment might sometimes 
very well deserve con?ideration, in comparison with delivery by turning." — Elem. 
Op'er. Mid. p. 233. 

I have already noticed this opinion of Dr. Davis, elicited by other considerations 
of this subject, at par. 657. I there suggested, and now repe it, that the use of the 
forceps, under such circumstances, must be uncertain, if not dangerous; and I must 
again declare, I think turning to be the proper operation, if necessary to have recourse 
to anv. 

t treatise, Vol. I. p. 221. 



264 CAUSES, SIGNS, AND ACCIDENTS OF THE LOCKED HEAD. 

Baudelocque's account of this situation of the head, is by far the most 
lucid I have met with ; he most successfully combats the opinions of 
Levret and Roederer upon the mechanism of this arrest of the head, 
and completely establishes his own doctrines upon this point. I have 
so rarely met with this situation of the head, that I feel almost alto- 
gether indebted to him for what I know upon the subject; I shall 
therefore adopt his account of this embarrassing case.* 

835. He admits but one general species of locking, and that is 
where the head is fixed by two points of its surface diametrically op- 
posite to each other : this species he divides into two varieties : 1st, 
where the head is jammed with its greatest length between the pubes 
and sacrum ; and, 2d., where its thickness cannot pass, owing to a 
narrowness of the pelvis : in the first case, it is the forehead and occi- 
put which are in contact with the inner edge of the pelvis ; and in the 
second, it is the parietal protuberances — this latter is the most rare. 

836. Whenever the head becomes locked, it acquires the form of a 
wedge ; Lamotte finely illustrates it, by comparing it to the keystone 
of an arch. 



Sect. I. — Of the Causes, Signs, and Occidents of the Locked Head. 

837. Several causes must concur to produce the locked head; 1st, 
the long-continued and vehement action of the uterus, and the aux- 
iliary powers of labour — therefore, this fixedness of the head never 
need be feared in a delicate woman, agreeably to Baudelocque ; 2dly, 
a disproportion between the pelvis and the head ; this disproportion 
may depend upon the mal-situation of the head, upon its great size 
and solidity, or upon the deformity of the pelvis. 

838. The immobility of the head is the pathognomonic sign of its 
being locked ; but after it has become fixed, other symptoms arise, 
which, if they do not characterize this situation, are sure to accom- 
pany it — such as swelling of the hairy scalp of the child, a thickening 
of the os uteri, an intumescence of the vagina and external parts. 
These symptoms do not always declare a locked head, but a locked 
head is never without them. When the pelvis is so small that the 
head cannot engage in it, certain symptoms take place, which agree- 
ably to Lamotte and Roederer, are sometimes mistaken for the signs 
of the locked head. 

839. A locked head is always serious to both mother and child, 
the mother it exposes to inflammation, sloughing, or gangrene ; and 
the child to almost certain death. 

840. The whole of the soft parts of the mother become injured, by 
the long-continued and violent pressure which the child's head exerts 
upon them; the vagina, rectum, and urethra, sometimes receive irre- 

* Madame La Chapelle, Velpeau informs us, has never met with, a case of locked 
head. 



INDICATIONS IN THE LOCKED HEAD. 265 

parable injury. The bladder also suffers from the accumulation of 
the urine, nor can it be relieved by the catheter as the canal of the 
urethra is entirely obliterated. 



Sect. II. — Indications in the Locked Head. 

841. The principal indication in the locked head, is the delivery 
of the child. This is to be effected by the forceps, in preference to any 
other means, so long as the child is living ; if its death be certain, the 
crotchet undoubtedly merits the preference. If we consult the older 
writers upon this subject, we shall find they all had recourse to the 
the crotchet upon such occasions ; and I am sorry to add, that too 
many living authors, as well as practitioners, are too fond of recom- 
mending or following their example. For, though the forceps do not 
always ensure safety to the child, they give it at least the best pos- 
sible chance ; they should, therefore, always be preferred. In this 
country, this terrible case is certainly very rare ; this is owing princi- 
pally to the healthy construction of the pelvis of our females. When 
it takes place, it almost always arises from the bad positions of the 
head, and these positions must be either the third or sixth — now, 
these, as has already been observed, are of extremely rare occurrence. 

842. I especially recommend the reader to consult Baudelocque's 
very useful chapter upon this subject; he will find much excellent 
practical matter besides the histories of several very interesting 
cases, which are of much more importance, particularly to the pro- 
fessed accoucheur. 

843. The locked head is sometimes confounded with a head 
merely arrested in its progress ; the stoppage may arise from, 1st. 
Whenever the head maintains its diagonal or transverse position at 
the lower strait; 2d. When the chin departs from the breast too 
early in ihe labour; 3d. When the lower strait is less than the ordi- 
nary size; 4th. When the external and internal parts make much 
resistance. 

844. For the removal of the first cause, we must bring the vertex 
towards the arch of the pubes ; by one blade of the forceps or by a 
lever: this is not very difficult to perform: I have succeeded in 
altering this position of the head by applying the extremity of the 
instrument upon the vertex, by passing it at the bottom and side of 
the pelvis, until it has passed under the head; we must then raise 
the edge of the blade, and insinuate it between the side of the pelvis 
and the vertex ; then, if the handle be pressed against the pcrinseum, 
its curve will be placed upon or near the posterior fontanelle. 
When thus fixed, we must draw the instrument downward and for- 
ward during a pain until we can move the vertex to its proper 
situation. When the head is thus changed, we may withdraw the 
vectis, and commit the rest to nature. 



266 METHOD OF USING THE FORCEPS IJN T THE LOCKED HEAD. 

845. The mode of treating the second case has already been ex- 
plained, (702, &c.) when speaking of this perverse situation of the 
head. When the arrest is owing to the smallness of the lower strait, 
as in the third, (843,) the head must be extracted by the forceps, 
unless the defect be excessive; and if excessive and the child dead, 
the crotchet must be used ; but if living, Baudelocque proposes the 
Csesarian operation. If the external and internal parts, as in the 
fourth case, (843) offer the resistance, blood-letting will be the 
remedy. 



Sect. III. — Method of Using the Forceps in the Locked Head. 

846. When the head is locked by its greatest diameter becoming 
wedged in the small diameter of the superior strait, it is either by 
the vertex or the forehead being towards the pubes. In using the 
forceps for either of these situations, we must conduct them so that 
they shall apply themselves over the ears of the child, or to the 
sides of the head. They must be so arranged, that the concave 
edges must be towards the part which will eventually come under 
the arch of the pubes. When the head is embraced, we must en- 
deavour to raise it up by a compound motion of the forceps; that is, 
by carrying the handles gently from side to side of the pelvis, and 
at the same time pushing the instruments upward, so as to raise it 
from its bed. When this is done, the vertex or forehead must be 
turned towards the left side of the pelvis, if practicable ; and when 
there, the motion we have already described must be given to the 
handles of the instruments, until either the vertex or forehead, as 
the case may be, is brought under the arch of the pubes. Baude- 
locque directs the head to be turned as it is brought along, but I do 
not think this necessary ; for when the head arrives at the inclined 
plane, formed by the sacro-ischiatic ligaments, it will turn towards 
the opening of the pelvis spontaneously, if the pains continue, and 
in due force. It must be recollected, in order that the instruments 
should be carried to such a height in the pelvis, that the handles 
must be kept well pressed against the perineeum. 

847. When the head is locked by the small diameter becoming 
jammed in the small diameter of the superior strait, the vertex must 
answer to either the right or the left side of the pelvis, and the con- 
cave part of the instruments must look towards it; consequently, 
there will be a choice of blade to be first introduced — if the vertex 
be to the left side, the male blade must be first, and the reverse. 
The head must be raised from out of the superior strait by the hand, 
and then the instruments must be directed over the sides of the head, 
and the traction must be in conformity with the axis of the upper 
strait; this direction is given by pressing the handles against the 
perinaeum. 



USE OF THE FORCEPS IN FACE PRESENTATIONS. 267 



CHAPTER XXIV. 

OF THE USE OF THE FORCEPS IN FACE PRESENTATIONS. 

S4S. In considering face presentations, I was inclined to restrict 
their number to two, instead of four, as described by Baudelocque — 
if I should not be correct in this reduction, I am at least sure, that the 
first and second of my arrangement, are by far the most frequent, and 
can safely say, I have never met with the third and fourth, though 
they were recognised by both Smellie and Baudelocque. Indeed, the 
presentation of the face in any position is of very rare occurrence ; I 
find I have met with it but ten times in more than ten thousand cases ;* 
and upon consulting the table furnished by " PHospice de la Maternite 
de Paris," I find, that of 12,751 women delivered in that institution, 
there were but forty face presentations ; and of that forty, but one of 
the first presentation of Baudelocque, and not one of the second ; 
whereas, of the third, there were twenty- two, and seventeen of my 
second. This is strong confirmation of the infrequency of the first and 
second positions of Baudelocque. 

849. When a labour in which the face presents becomes complicated 
by any of the before enumerated causes, (651 ;) or if it is rendered 
impracticable without the application of adventitious aid, from mere 
position ; and that aid consist in the proper application of the hand, 
and it prove insufficient for its accomplishment, we must resort to in- 
strumental delivery — this will compehend the use of the vectis, the 
application of the forceps, or the employment of the crotchet. 

850. Of the mode of using the vectis I have already spoken ;f the 
forceps I consider of doubtful efficacy, not so much from the difficulty 
of application, as their mode of action in these particular cases ; though 
it would seem, Smellie had succeeded with them. I would, however, 
wish to be understood, in speaking of the use of these instruments, 

* It is a little remarkable, that lately I met with two cases of face presentation 
within a week of each other, and a third within three months of these two; making 1 
nearly half the number, I have ever encountered. 

t Baud., locque's method of using the lever in this case, (System, Vol. III. par. 1836,) 
appears to me to be defective; as I have already stated. I have, in a few instances, 
used as described before with the most decided advantage — but how far it may be 
successful as a general practice, I have yet t > learn ; for I again declare my experience 
in face cases to be very limited; but it appears to me to be more consonant with the 
principle to be acted upon in such cases; which is to reduce the vertex, and elevate 
the chin. But agreeably to him we must act forcibly upon the vertex, that it may 
41 be sufficiently brought down ;" but we cannot bring the vertex down alone by his 
plan, as the face will descend with it by obeying the same impulse which moved the 
ver'ex. Now, this disadvantage is avoided by the plan I propose; namely, after fixing 
the vectis properly upon the occiput, we apply no more force lo it than is sufficient to 
prevent it from rising in the pelvis, at the time we are acting on the face, by applying 
two fingers immediately at the extremity of the nose, and upon the upper jaw. 



268 USE OF THE FORCEPS IN FACE PRESENTATIONS. 

that I confine my observations entirely to the first two presentations 
of the present arrangement,* or where the head is situated transversely 
in the pelvis. In such situations of the face, we are told, by both 
Smellie and Baudelocque, that " we must use the forceps ;" the latter 
declaring, that " when we cannot rectify the relation of the face to the 
pelvis by the plan already advised, or without great danger to the 
mother, because the head is strongly wedged, and the uterus contract- 
ed and closed upon the child," — "we must use the forceps to bring 
the head along in the attitude we find it in," because fewer incon- 
veniences result from it to mother and child than from any other 
method. 

851. Should the forceps be determined on, we must apply them 
over the ears ; that is, one blade behind the pubes, and the other before 
the scrotum ; they must be so applied that the concave edges must 
look towards the hind head, which must be brought under the arch 
of the pubes, and not the chin, as directed by Smellie. 

852. Should all the reasons exist for using the forceps, and their 
application not prove successful, I feel that this is one of the very few 
cases where the application of the crotchet is justifiable for the preser- 
vation of the mother, however repugnant I may be to its use, or how- 
ever revolting it may be in its consequences. 

853. Having considered all the most frequent and better know r n 
presentations of the head-,' with the various modes of conducting them 
when nature is sufficient to their accomplishment; the mode of opera- 
ting by the hand alone when she is incompetent to this end, and the 
use of instruments when it becomes essential from this cause to employ 
them ; I shall not consume the reader's time or patience by describing 
a variety of other presentations of this part as laid down by authors ; 
first, because I never have seen them ; and, secondly, because I believe 
if they really exist, they must all, or with very few exceptions, be 
treated by turning: as I shall direct for many other rare and perverse 
positions which the child's body may assume at the orifice of the 
uterus. 

854. Nor shall I spend time in describing the form of the vectis or 
its mode of application ; because the one would be totally unnecessary 
without the other ; and I decline the latter, because I am not in the 
habit of using this instrument, except in rectifying bad positions of the 
head ; and for this purpose I have always found one of the blades of 
the forceps sufficient. I consider the vectis inferior to the forceps, in 
power, safety, and convenience: and I am truly glad to perceive the 
change which has taken place in the public mind, since the accurate 
and elaborate analysis of its merits, by the judicious Baudelocque, has 
been before the public. 

* The third and fourth are so rare, or rather their possibility so doubtful, that I do 
not think it worth while to notice them farther than I have already done — those desi- 
rous of seeing all that can be said upon these positions, are referred to Smellie and 
Baudelocque. 



PRESENTATION OF THE BREECH. 369 

855. I am also pleased to find a change in Mr. Burns'* opinion 
upon the subject of the vectis : he says that " a young practitioner shall 
be less apt to injure his patient, and less likely to be foiled, with the 
forceps than the vectis ;" and particularly gratified that Dr. James, 
in a note to this paragraph, expresses the same belief. The latter 
gentleman's opinion, upon this and every other point connected with 
our subject, is highly valuable; especially in this country, where the 
opportunities to test the respective merits of these instruments can fall 
to the lot of no one who is not extensively, and for a long period, 
engaged in obstetrics ; for the facility of labours among our females, 
owing to the almost entire exemption from rickets and other causes 
which render this process one of much more difficulty in Europe, 
give comparatively few opportunities to decide upon their respective 
claims. 

856. I have for many years felt the superiority of the forceps over 
the vectis ; but was reluctant publicly to express it, from an appre- 
hension that I might have mistaken my own mal-adroitness in using 
the latter, for an imperfection in the instrument itself; but strength- 
ened by the opinion of Dr. James, I have no longer any hesitation 
upon this subject. 



CHAPTER XXV. 



PRESENTATIONS OF THE BREECH. J 



857. The presentation next in frequency is that of the breech, 
though not so arranged by Baudelocque ; but as I before stated, I 
think it a good rule, to treat of labours in the order of their frequency. 
The breech may with great propriety be considered as a variety of 
natural labour ; since the woman most frequently is able to relieve 
herself, if we except, perhaps, a first child ; though the process may 
be longer, and more painful, than when the vertex presents in one of 
its best manners. And, were I to institute a comparison between the 
two, I should say it is not ordinarily more painful than the fourth or 
fifth vertex presentation. I think also that this presentation is more 
favourable for the child, than either the feet or knees; especially in 
first labours ; though the operation, generally speaking, is slower; and, 
perhaps, more fatiguing to the mother. 

* Principles, James' ed. 1823, Vol. I. p. 447. 

t Of 20,517 births, 373 presented the breech. Of thesr\ 217 were cf the l«t pre- 
sentation ;— 140 of the 2d;— G of the 3d; 10 of the 4th. We think it probable thrreis 
an error in this, as it happens, oftener (agreeably to this account) than the third; an 
occurrence wo very much doubt. 

24 



370 PRESENTATION OF THE BREECH. 

858. The risk, in all the labours, whether natural or artificial, in 
which the child's body is first delivered, arises from the delay in the 
delivery of the head, and the compression of the umbilical cord. 
Now, the latter very frequently depends upon the former ; and the 
former upon the bad position of the head as regards the pelvis: or 
from the rigidity of the external parts. This being the case, it is evi- 
dent, that the risk from the delay of the head at the inferior strait in 
consequence of the want of dilatation of the external parts, must be 
less in presentations of the breech, than in the presentations of the 
feet and knees ; because, its bulk being nearly equal to that of the 
head, will by passing through those parts so effectually dilate them, 
as very much to diminish the risk of such delay. On this account, I 
think breech labours, cseteris paribus, safer to the child than those of 
the feet or knees, though they are not generally so considered.* 

859. The presence of the breech at the orifice of the uterus, can- 
not be very well ascertained or distinguished, before the membranes 
are ruptured and the uterus pretty well dilated. Under proper cir- 
cumstances it may be known, by its forming a large softish tumour in 
the pelvis, which wants the characters of the head, with which it is 
alone liable to be confounded ; for it has neither the sutures, nor the 
hardness of this part; nor the roughness of the hairy scalp. A deep 
groove is observed in the centre of this part, which, when traced, 
leads to the detection of the anus, and the parts of generation. A 
discharge of meconium, after the membranes have given way, tends 
to corroborate, but does not absolutely confirm the presence of the 
breech, f 

It must, however, be confessed, that there is sometimes a great 
deal of difficulty in deciding whether the presentation be the head or 
the breech — the former, when very much swoln by becoming locked, 
may resemble the breech ; and the latter when very tumid, may have 
its principal signs so masked, as to render it doubtful whether it be 
breech or head. Baudelocque (System, Vol. I. par. 1251,) tells us of 
an experienced practitioner, who mistook the breech for a locked 
head, and delivered it with the forceps.J In all cases of ambiguity, 
I have constantly made it a practice to introduce the hand, to ascer- 

* Baudelocque (System, Vol. I. par. 766) say?, that " delivery may be generally per- 
formed as naturally when the child presents the breech, as when it offers the feet or 
knees ; only that, caeteris paribus, it will be a little longer, and more difficult; because 
the child does not then form so regular and lengthened a wedge, as when the lower 
extremities are unfolded." I agree, that it may be " a little longer and more difficult" 
to the mother ; but, for the reasons above stated, I think it sifer for the child. 

f It is Leveret, I think, who mentions a case in which there was a considerable dis- 
charge of meconium, though the head presented; and I am certain of having met with 
one case, if not more, of a similar kind. 

X Dr. Blundell is rather and advocate in his Lectures for this mode of treating breech 
presentation. He says, " There is yet another mode in which you may assist the de- 
scent of the breech ; and which, I think, worth your knowing, though I do not recom- 
mend ii to general practice ; — and this is, by the u*e of the forceps. Nor am I de- 
terred from the forceps by the alarm of Capuron, who asserts, the use of the forceps 
in this case to be toujours dangereux si non me eurtrier pour l'enfant." He thinks 
you may bruise the sides of the viscera of the abdomen by the application of the for- 



MECHANISM OF THE FIRST. 271 

tain the nature of the presentation whenever it becomes important to 
decide the point. 

Sect. I. — Species of the Breech Presentations. 

S60. There are four principal manners in which the breech may 
present at the upper part of the pelvis ; a, the first is where the lower 
part of the spine and sacrum offers to the left acetabulum, while its 
abdomen looks towards the right sacro-iliac symphysis; b, 2d., 
where the back part of the child answers to the right acetabulum, and 
the belly to the left sacro-iliac junction ; c, 3d., where the spine and 
sacrum are behind the symphysis pubis, and the belly towards the 
projection of the sacrum ; d, 4th., the reverse of this. 



Sect. II. — a. .Mechanism of the First Presentation of the Breech. 

861. In this presentation the oblique situation of the breech, at the 
upper strait is soon changed by the contraction of the uterus into one 
almost strictly transversal ; so that the spine will at one time be found 
behind the symphysis pubis : but, soon after, the left hip or spine of 
the ilium will be made to offer itself uncler the arch of these bones, 
while the right will be resting upon a part of the sacrum, and the in- 
clined plane formed by the left sacro-ischiatic ligaments. The spine 
of the child will rest against the left leg of the pubes, and the hip, 
which is under the arch, will rise upwards, while the right will turn 
into the hollow of the sacrum, and travel successively over the point 
of the coccyx and the face of the perineum, to offer itself at the bot- 
tom of the vulva, that it may escape through the external parts ; 
which presently it does, with the other portions of the breech, Try 
rising by a slight bend of the spine towards the mons veneris. 

862. When the breech has passed a sufficient distance through the 
os externum, the legs of the child fall down, and the remaining por- 
tion of the body, by the successive contractions of the uterus, will 
be delivered by passing a little obliquely through the external opening 
of the pelvis. When the armpits descend to the superior strait, there 
is a momentary interruption to the farther descent of the body of the 
child, occasioned by the size of the shoulders and position of the 
arms ; but, from the pliant disposition of these parts, it is but tem- 
porary — for they are made to accommodate themselves to the shape 
of the pelvis, by the repeated contraction of the uterus. The head 
now offers itself to the upper opening of the pelvis, the occiput is 
behind the left acetabulum, and the face before the right sacro-iliac 
junction. The chin will descend sooner than the occiput, in conse- 
quence of its having been placed against the breast of the child. 

ceps lo the breech ; and so you may, if you use force ; but force, I have told you is to 
be exploded from midwifery. If you lay hold of the hips with the forceps you may 
grasp with readiness. 



272 PRESENTATIONS OF THE BREECH. 

863. As soon as the head clears the superior strait, the forehead 
inclines towards the hollow of the sacrum by the same pivot-like mo- 
tion which it performs to place the vertex under the arch of the pubes, 
in vertex presentations. The nape of the neck will now be under the 
arch of the pubes, while the face will be lying on the face of the 
perinasum. The chin will first escape from the vulva ; the other 
parts of the face, and anterior part of the head, will successively 
follow; while the nape of the neck will execute a slight circular mo- 
tion under the arch of the pubes ; the arms are liberated so soon al- 
most as the shoulders are pushed through the os externum.* 



Sect. III. — b. Mechanism of the Second Presentation of the 
Breech. 

864. In this presentation, the mechanism is precisely the same as 
that of the first : on the part of the child we must only substitute the 
right hip, offering at the arch of the pubes, for the left, as in the first 
presentation ; and at the last period of the labour, the vertex or occi- 
put will be placed at the right side of the pelvis instead of the left. 
On the part of the pelvis, it is the right acetabulum, behind which the 
breech offers, &c. 



Sect. IV. — c. Mechanism of the Third Presentation of the Breech. 

865. In this presentation, the breech engages in the superior strait, 
with its greatest width parallel to its large or transverse diameter — 
the spine passes immediately behind the symphysis pubis, and it be- 
comes a matter of some uncertainty which hip will offer under it ; but, 
which ever it may be, it passes through a little obliquely, as in the 
other presentations. Though in this position the face of the child 
looks directly to the projection of the sacrum, it seldom happens that 
the head becomes jammed with its greatest diameter, in the small 
diameter of the superior strait ; it is therefore, almost always, found 
to place itself diagonally, and pass down in that direction, as in the 
two former presentations. 

866. When the breech becomes free, the labour proceeds com- 
monly as has been described in the first and second positions, as it 
may be the left or the right hip which offers to the arch of the pubes. 



Sect. V. — d. Mechanism of the Fourth Presentation of the Breech. 

867. The only difference in the mechanism of the third and fourth 
of these presentations, is, that instead of the face being placed below, 

* It must be borne in mind,, that a strictly natural delivery is here described; or, in 
other words, where no adventitious aid is required. 



PRESENTATIONS OF THE BREECH. 273 

as in the third, it is found to be looking up, which creates the only- 
peculiar difficulty in this case. The risk of the head engaging with 
its greatest length in the smaller diameter of the superior strait, is 
perhaps greater in this than in the third — but should this take place 
in either, difficulty might be created. The fourth presentation is de- 
cidedly a rare one — I have met with it but once ; and upon examining, 
the returns from " l'Hospice de la Maternite," but one case is re- 
corded in more than 12,000. When it occurs; and we have not lost 
the opportunity, we should always seek for the feet, and deliver by 
them. 

S6S. I have already observed, that all the presentations of the 
breech are attended with slower, and more painful labours ; and that 
the child very frequently suffers. This is especially the case where 
the labour has been improperly interfered with, either by rupturing 
the membranes unseasonably, or under the influence of false princi- 
ples, seeking the feet, and causing the child to pass rapidly through 
the external parts, before they are properly relaxed ; in consequence 
of this, the head becomes wedged in the inferior strait. Then, under 
the direction of the same erroneous views, it is attempted to deliver 
it quickly, by making force supply the place of address ; and the child 
becomes the victim of this unnecessary and ill-directed violence. 

869. It must constantly be recollected, in all cases in which the 
head is the last part to be delivered, that when it offers itself to the os 
externum, it is entirely from under the direct control of uterine action ; 
the auxiliary and voluntary powers alone have an influence on it at 
this period of labour ; and though external force may, and almost al- 
ways does become necessary to terminate the labour, it must always 
be made to co-operate with these powers, by soliciting the woman to 
exert them as amply as may be in her power. 



CHAPTER XXVI. 



CAUSES WHICH OER PRESENTATIONS OI-> THE ERLECH Ti.. 

NATURAL. 

HE presentation of the breech, like any other presentation, 
may be complicated by cither of the accidents enumerated in par. 
601, and must, when thus complicated, be interfered with, whenever 
such a combination may render the labour difficult or dan.. 

. Besides the causes just alluded to, there may be others con- 
nected with the child itself, which should cause us to aid in the de- 
livery of the woman. But in the absence of such causes, and especi- 

24* 



275 CAUSES RENDERING- BREECH PRESENTATIONS 

ally in a first labour, the process should be left to the powers of nature 
alone ; or at least until the breech is delivered. 

872. I am aware that many respectable practitioners are in the 
habit of introducing the hand and bringing down the feet, in all 
cases of breech presentation; but I am abundantly convinced, that, 
as a general rule, it saves the mother nothing, and that it is highly 
dangerous to the chtid* I am of opinion that this practice is often 
the result of the classification of labours, as breech presentations are 
almost uniformly placed in the preternatural class; it has, therefore, 
been too easily supposed that such cases always require extrinsic 
aid. May not this be one of the reasons why so many children 
perish in this presentation? What the general practice in breech 
presentations may be in Great Britain, I am not prepared to say : 
but the result is extremely unfavourable ; since Dr. Denman says, 
"I have considered one child in three of those born with these pre- 
sentations, to be still-born." This proportion by no means coincides 
with my experience in such cases; the average of living children 
would be considerably greater, though a number of my cases were 
second hand, and in which the first stages of labour had been very 
often ill-conducted ; I, nevertheless, think Portal's proportion rather 
too little for France, where there must necessarily be very many 
faulty pelves to contend with, as he makes but twenty per cent., 
while Dr. Denman's is thirty-three — in this country, where we but 
very rarely meet with a deformity of pelvis ; when there is not an 
excess of size in the breech; and when the earlier stages of labour 
have not been disturbed, by ill-timed omciousness, or an entire 
ignorance of the correct rationale of such cases, I am, I think war- 
ranted in saying, that the number of still-born children from breech 
presentations, might be reduced to very few. But the result of cases 
in which the breech, the knees, or the feet present, agreeably to the 
records of " la Matemite" is, that one child in eight perishes, which 
is again very much less than the proportions, established by Denman 
and Portal, and can, perhaps, only be satisfactorily accounted for, by 
supposing that in that institution a better treatment is established for 
these cases. Yet we confess, on the other hand,, that the proportion 
of still-born children in the same hospital, to those born alive is, 
judging by my own experience, excessive ; namely, one in thirty-two. 
In this country, under favourable management, we do not think 
there is one in fifty, if we select, as we think we should, only such 

* Dr. Blundell relates the following' instructive anecdote : — Dr. Lamcler was called 
to see a woman labouring under the presentation of the nates ; the labour being diffi- 
cult, because the breech was large, and the pelvis small. The action of the womb 
being powerful, however, the breech was pushed to the outlet of the pelvis, and the ac- 
coucheur laying hold of the hips, assisted a little with his characteristic gentleness, 
but suffered the legs to drop of themselves. To this case a midwife had been called — 
and afier the doctor had brought away the child, she went up to it and examined the 
thighs, and turning round with surprise, exclaimed, ' Why, you have not broken the 
thighs ? ' No,' said the doctor, 'why should I break the child's thighs ? • Why,? said, 
she, ' I always break the thighs.' "—Prin. and Prac. of Obstet.p. 202. 



PRETERNATURAL, AND MODE OF TREATMENT. 274 

cases in which children die in the birth, and this we presume is the 
mode of calculation in Paris, as the comparison is instituted between 
the head, breech, feet, and knees, cases. This disparity induced M. 
Baudelocque, nephew to the celebrated accoucheur, to inquire into 
the cause, which he declares to be always the same; namely, to the 
interruption of circulation between the mother and child, which con- 
stantly produces a sanguinous congestion, either in the brain or in the 
liver, and thus adopting the opinions of Chaussier, Madame Lacha- 
pelle and Duges. 

He does not agree with his uncle, that the stretching of the ver- 
tebral column is a frequent cause (736) of death in other than head 
presentations, and strengthens the general position, by the testimony 
of Mdme Lachapelle, who declares she has seen children born alive, 
when so much force had been applied as to cause a cracking noise 
from the tearing of the ligament of the cervical ligaments. But let us 
not be deceived upon this point, and be disposed to believe that the 
severe stretching of the cervical vertebrae is free from danger to the 
child ; on the contrary, we are certain, that if it be severe, it is always 
fatal to the child, though it may not be the only cause of its death. 

873. But should any one of the accidents which may disturb a 
labour assail a woman whose child is presenting the breech, we are 
justified in giving such assistance as the exigency of the case may 
demand. The kind of aid we are to give will depend upon, 1st. a. 
The degree of advancement, or the part of the pelvis at which the 
breech may be at the time ; 2d. b. The position of the child ; and 
3d. c. The size of the breech. 



a. — First Degree of Advancement. 

874. An accident threatening or endangering the life of the mother, 
may, a, attack her at the very commencement of labour, and where 
the child is still at the superior strait; 6, it may attack, when the 
breech is pretty low in the pelvis, but still included by the uterus ; 
c, it may attack when the breech is at the lower strait, but escaped 
from the uterus. 

875. a. This may happen when the uterus is well dilated, or 
easily dilatable, or when rigid ; the membranes may be either entire 
or just ruptured, or ruptured a long time. 

876. Should any circumstance render it necessary to deliver the 
woman when labour is but little advanced ; the breech at the supe- 
rior strait, or near it; the uterus dilated or dilatable ; the membranes 
entire or just ruptured ; we must without hesitation introduce the 
hand and bring down the feet, and finish the delivery as directed, 
when turning is employed for a vertex presentation. But should the 
uterus be still shut, or but little opened and rigid, nothing should tempt 
us to enter the uterus forcibly, with a view to bringdown the feet and 
deliver; especially, if the membranes are entire: as, under such 



276 CAUSES RENDERING BREECH PRESENTATIONS 

circumstances, there must be a reasonable expectation that the uterus 
will soon dilate, at least Sufficiently to pass the hand without vio- 
lence. As I have constantly inculcated the impropriety of dilating 
the uterus by force, whenever the labour is complicated by any 
supervening accident, I must be understood to make no exception 
here in favour of this presentation ; therefore, when the uterus is 
rigid, and but little opened, we must treat the case by temporizing, 
agreeably to the nature of the accident, until either the remedies, 
or the influence of the accident, or the powers of the uterus itself 
shall make such change as will render the attempt at bringing down 
the feet proper and safe. 



b. Second Degree of Advancement. 

877. b. It may attack when the breech is pretty low in the pelvis,, 
but still included in the uterus : this may happen when the uterus is- 
well dilated or easily dilatable, or when rigid and unyielding ; and 
when the membranes are entire or just ruptured ; or when the waters 
have been drained off a long time, and the uterus is firmly embracing 
the body of the child. 

878. In the first instance, or where the uterus is in a condition to 
transmit the hand without much force, the membranes entire, or the 
waters but lately passed off, we should bring down the feet as directed 
in the former instance, and finish the labour after the same manner. 
But should the os uteri be rigid, whether the membranes be entire or 
not, we must not force the mouth of the uterus, with a view to ter- 
minate the labour; but as just suggested, temporize, until the uterus 
will permit the hand to pass for this purpose, without difficulty ; for 
it will rarely happen, even where the waters have long escaped, that 
we cannot pass the hand to the margin of the pelvis, and seize the 
feet, provided the proper hand be employed.. 



c. Third Degree of Advancement. 

879. c. It may attack when the breech is at the lower strait, but 
passed through the mouth of the uterus. This situation necessarily 
presupposes the dilatation of the uterus, and almost certainly the escape 
of the waters. In this condition of the breech and uterus we must 
not attempt to bring down the feet, unless the breech be ver}< small, 
or the pelvis very ample, and the woman without pains, or at least 
efficient ones : for if they are protrusive, and under the circumstances 
j,ust mentioned, they will deliver the breech in good time, or in such 
time as will prevent any serious inconvenience from the delay. But 
should the breech be large, and occupy the lower strait very strictly? 
we should not attempt to finish the labour by bringing down the feet* 



PRETERNATURAL, AND MODE OF TREATMENT. 



277 



In this case, we must assist the passage of the breech by acting, 1st, 
with the fingers ; 2dly, by the fillet; 3dly, by the blunt hook or hooks. 

880. When the breech is very low in the pelvis, or so low that we 
can place a finger into the groin, we may, by the forces so applied, 
aid the descent of the breech ; especially if the uterus by its con- 
tractions still powerfully co-operate with our exertions. Whenever 
attainable, we should prefer that groin which is most posterior to the 
arch of the pubes, when but one at a time can be operated on. If 
both groins can be reached, we may insinuate a finger of each hand 
into them, and have this double power to assist the breech to descend. 

SSI. Should the force just directed be too feeble for the purpose, 
or too fatiguing to the operator, he may substitute the fillet with very 
great advantage. Baudelocque (System, par. 1267,) makes a dispa- 
raging mention of this power : he says, "its application is so difficult, 
that it is with a sort of repugnance that he reckons it among the re- 
sources of art." That it is sometimes difficult in its application, I 
readily admit ; but it is by no means impracticable, when the breech 
occupies the lower strait. If the passing of the fillet be attempted 
when the breech is pretty remote from the os externum, we may cer- 
tainly be foiled ; but this is not a case proper for this instrument ; for 
it can only be used when the point of the finger can command the 
groin. 

882. This fillet should consist of a piece of silk riband of an inch 
and a quarter or half wide, and at least two feet and a half long. 
When doubled, the point of the forefinger must be placed in the centre 
of the fold and kept tight upon it, by drawing it sufficiently with the 
other hand — the parts of the woman and the fillet should both be im- 
bued with lard or sweet oil, and the riband then passed into the 
vagina by the point of the finger, and conducted over the hip and 
into the groin towards the parts of generation of the child, as far as 
the point of the finger can reach ; the finger is then to be retracted a 
little, that it may gather upon its point another fold or fillet, which it 
also carries forward as far as it can reach : and this to be repeated 
for several times, until the folds so multiply in the groin as to move 
each other forward, so as to appear at the other extremity of it — when 
there, it may be drawn down by the forefinger of the other hand, in- 
troduced, after the first is withdrawn from the vagina ; or it may be 
hooked, as proposed by Baudelocque, and as I have myself prac- 
tised, by a hook, made extemporaneously, of a piece of pretty stiff 
wire. 

883. When the fold of the fillet is seized by the finger and thumb, 
or hooked by the instrument just mentioned, we are to take hold of 
one of the outer extremities of it with one hand, while we draw the 
other end through the groin, by gaining successive portions of it. 
When the fillet is thus made single in the groin, we take hold of both 
extremities of the riband, and secure a good hold by passing it several 
times round some of the fingers. We then co-operate with the pains 
if there be any, by pulling in the direction of the axis of the lower 



278 CAUSES RENDERING BREEGH PRESENTATIONS 

strait, until the breech is relieved from the pelvis. But if the pains 
have ceased, we draw at intervals ; at the same time, we solicit the co- 
operation of the patient. 

884. But should we not be able to pass the fillet, because the breech 
is too remote from the finger, or because the breech is very large, and 
firmly impacted in the pelvis, we must then attempt assistance, by 
employing the blunt hook, or hooks. I have found more than once, 
the hook at the extremities of the French forceps answer extremely 
well, as Baudelocque long since suggested. But that they may be 
employed with advantage, they must stand very nearly at right angles 
with their stems ; for if they are too much depressed, they cannot be 
introduced into the groins ; for this reason I would advise every gen- 
tleman who may adopt these instruments, to attend to this circum- 
stance at the time he is purchasing-them. 

885. The mode of using the blunt hook, is by first placing the point 
of the forefinger upon the groove which leads to the groin : then pass 
the handle of the forceps into the vagina, with the point of the hook 
looking upward or towards the point of the inserted finger, until it 
comes in contact with it ; then, by altering the position of the hook, 
and making it take the place of the finger, by a gentle pressure, it may 
be placed in the groin : when thus placed, w r e must aid the descent of 
the breech by pulling at the external extremity of the instrument in 
the direction of the axis of that part of the pelvis through w 7 hich the 
breech is to pass. 

886. Baudelocque proposes blunt hooks to join something like the 
forceps for this operation ; but this I do not think necessary ; for when 
both groins can be commanded, and it is essential from the nature of 
the difficulties attending the labour to act upon both of them at the 
same time, both handles of the forceps, I am of opinion, may be em- 
ployed advantageously, without being united — but I confess this to 
be conjecture ; for I have had no experience of it. 

887. When the breech is situated obliquely at the low T er strait, we 
should apply the force, whenever practicable, to the groin which offers 
to the sacro-iliac symphysis, or side of the sacrum ; as this hip should 
advance faster than the other, that it may arrive at the bottom of the 
vulva to escape through the os externum. When placed transversely, 
we may act upon either, or both groins, until the breech is about to 
pass under the arch of the pubes — when there, we should endeavour 
to depress one of the groins, that the ilium may come under the arch, 
instead of the sacrum and spine, unless it does so spontaneously. 



Sect. I.- — 1. Position of the Child. 

888. The child may present so untowardly at the superior strait in 
consequence of a severe obliquity of the uterus, as to be unable to 
engage in it. In such case, one of the hips may only present itself 
to the opening of the pelvis ; of course the labour, if not rectified by 



PRETERNATURAL, AND MODE OF TREATMENT. 279 

changing the position of the woman, will be very tedious and painful 
or even dangerous. This situation of the hip will of itself, offer great 
embarrassment to the woman delivering herself; and often render it 
proper that we interfere without delay ; but when this position is attend- 
ed with either of the accidents heretofore enumerated, it becomes 
indispensable that we bring down the feet ; provided the conditions 
on the part of the uterus just mentioned, do not render that operation 
improper. 

889. Should the breech present in the fourth position, and this be 
ascertained immediately after the rupture of the membranes, it would, 
I believe, always be best to bring down the feet ; provided the uterus 
be sufficiently relaxed to permit the hand to pass without difficulty ; 
but should this presentation be complicated by any accident, it will 
become absolutely necessary ; but it must be under the provisions just 
stated. 



Sect. II. — 2. Size of the Breech, 

890. The breech may be absolutely, or relatively large as regards 
the pelvis : in either case, the same difficulties will be experienced. 
If the labour be left to itself, it may consume so much of the woman's 
strength as to render her situation precarious, unless recourse be had 
to adventitious aid. This case maybe complicated by any of the ac- 
cidents already enumerated ; or its difficulties may be increased, by 
being a fourth presentation. 

891. When sufficient time has been given, without advantage to 
the labour, and the cause of the delay satisfactorily ascertained, we 
should interpose and save the patient much unavailing pain. The 
nature of the assistance to be given must depend, 1st, upon the con- 
dition of the uterus, and the degree of advancement of the breech ; 
and 2dly, whether it be still contained, or has escaped, from the mouth 
of the uterus. In the first case we must bring down the feet so soon 
as the uterus will permit ; and in the second, also, provided the breech 
is still within the uterus, and the waters but recently drained off; but 
if it has escaped from the orifice of the uterus, we must employ the 
fingers, the fillet, or the blunt hook, as may appear expedient. 



Sect. III. — Tlie Mode of bringing; down the Feet, in the First Presen- 
tation of the Breech. 

892. The success of this operation very much depends upon the 
choice of the hand to be employed. The rule on this subject is ex- 
tremely simple — the hand, the palm of which will answer to the 
anterior parts of the child, is always to be used. In this presentation, 
then, the left hand will be the proper one for bringing down the feet. 
It must be introduced with due attention to the rules already laid down, 



280 CAUSES RENDERING BREECH PRESENTATIONS 

when speaking of turning, and passed upwards before the right sacro- 
iliac symphysis, until it can grasp the breech — which must be raised, 
and carried into the left iliac fossa. We must then search for the feet, 
by tracing the posterior part of the thighs and legs, until we arrive at 
them ; they must be seized as before directed, and brought down. 

893. If but one foot can be obtained, we may attempt the delivery, 
by acting upon it alone ; but when practicable, it is best to search for 
the other, unless it will require too much force. It will rarely hap- 
pen, if the breech be small, that much difficulty will be experienced 
in doing this ; but this is precisely the case in which we can almost 
always succeed, by applying the force to one. When delivering by 
one foot only, we should be very mindful of the direction in which 
we act upon it — we should always direct our force so as to carry the 
leg towards the retained one, lest we fracture or dislocate the thigh ; 
and, when the folded leg begins to appear, we may assist it by acting 
with a finger on the groin. When the breech is without, we must 
conduct the body along, until the other leg and foot fall down of 
themselves. 

894. W T hen the breech is still within the uterus, and occupies the 
lower strait, we can very often, should the necessity of the case require 
it, gain the feet, and enable us to expedite the labour ; provided the 
waters have not been too long drained off; the pains feeble ; and if 
the breech is not of an unusual size. But if the breech has passed 
the os uteri, we must not think of this expedient — when thus situated, 
the fingers, the fillet, or the blunt hook, must be our aids. 



Sect. IV. — The Mode in the Second Presentation of the Breech. 

895. A proper choice of the hand must be made in this presenta- 
tion, as well as in the preceding — when the emergency of the case 
requires bringing the feet down, we must make use of the right hand 
instead of the left, and conduct the rest of the operation in every re- 
spect as just directed. If but one foot can be obtained, we must pro- 
ceed with it to finish the labour ; but always recollecting the conditions 
which would render this partial action safe and proper. (893.) Should 
the breech, however, have escaped from the mouth of the uterus, it 
would be highly improper to pass up the hand with a view to bring 
down the feet — the aids just indicated (879) must then be resorted to. 



Sect. V. — The Mode in the Third Presentation of the Breech. 

896. The spine of the child, in this presentation, is to the sym- 
physis pubis, and the abdomen to the projection of the sacrum — this 
position is less favourable than the first and second, owing to the risk 
of having the head to engage with its greatest length parallel to the 



PRETERNATURAL, AND MODE OF TREATMENT. 281 

small diameter of the superior strait : this, however, is not a necessary 
consequence of this presentation, as we have already observed. 

897. In this presentation, either hand may be used. When re- 
quired to act, the hand must take a firm hold of the breech, as direct- 
ed for the raising of the head, and carry it forward and upward, over 
the pubes, and then pass the hand along the legs, until the feet can 
be reached: they must now be brought down, as heretofore directed; 
only observing, when the feet are entirely without, to turn the breech 
so as to make the body have an oblique position as regards the pelvis. 



Sect. VI. — The Mode in the Fourth Presentation of the Breech. 

89S. I have already remarked how very rare this presentation is ; 
but when it does occur, there can be no doubt of the propriety, if 
called to the case in proper time, of always searching for the feet. In 
this presentation, either hand may be used, as mentioned for the third ; 
only observing, that the breech, in this case, if possible, must be 
carried to one of the iliac fossae ; to the right, if we use the right hand, 
and the reverse, that the body may enter the superior strait obliquely, 
so as to give the chance to the face to turn from the pubes — after this, 
we search for the feet, and bring them down as directed. When the 
breech is without, we must attempt to give an oblique position to the 
body, if it has not already acquired it. It does not necessarily follow, 
however, that this case will be attended with more difficulty than 
those just spoken of; as the child may be very small, or the pelvis 
very ample. In either instance the woman would be enabled to de- 
liver herself. 

899. It maybe proper to observe, that all breech cases are to be 
subject to the rules I have endeavoured to inculcate for the safety 
of the uterus: 1st. That no severity of accident can justify forcing 
a passage into the uterus, with an intention of gaining the feet when 
the os uteri is unyielding. 2d. That when the breach is very large, 
the waters long drained off, the uterus firmly contracted on the body 
of the child, and much force would be required, (whatever address 
the accoucheur may possess,) the feet must not be sought for; but the 
labour must be terminated by the other agents already indicated. 
(879.) 3d. But when the uterus is in proper condition, and the 
membranes just ruptured, or the contractions not severe, though the 
waters may have escaped some time, we should lose no time by tem- 
porizing, when the accident is of a nature to render interference im- 
portant to mother and child. 



25 



282 



THE USE OF THE FORCEPS, 



CHAPTER XXVII. 



THE USE OF THE FORCEPS WHEN" THE BODY OF THE CHILD IS 
DELIVERED AND THE HEAD RETAINED. 

900. The risk the child always runs when its body is delivered first 7 
is so great, as to make us look upon such labours as hazardous, whether 
the necessity for this consideration be naturally or artificially created. 
I have already adverted to this ; but it may still be useful to repeat, 
that the danger to the child arises, 1st. From thesevere extension to 
which the cervical vertebrae may be liable, when it is necessary to 
employ force for the deliverance of the head ; 2d. The almost inevi- 
table compression of the cord, if the head be large, either positively or 
relatively, as it will be caught almost necessarily between the head and 
pelvis, or if it be tightly stretched, by its passing between the legs of 
the child, and we are unable to relieve it, &c. These causes pretty- 
constantly operate, where the head is the last part to be delivered, 
unless the pelvis be very ample, or the head small, and the external 
parts disposed to yield readily, and the mechanism of this part of the 
labour well understood. The mode, by which the remote causes just 
enumerated effect the death of the child is not clearly understood at 
this moment as it should be, considering its importance ; and this 
seems to be admitted on all hands, and will, we trust, elicit farther 
inquiry. MM. Baudelocque (nephew to the celebrated accoucheur) 
and Hervey de Chegoin, have offered some valuable observations, in 
" A Report on two new propositions by M. Baudelocque, junior, for 
preserving the life of the foetus when it presents the breech, feet or 
knees ; made to the Royal Academy of Medicine by M. Hervey de 
Chegoin." 

We think these observations so deserving of being more generally 
known, that we attach them to our text. And we farther think, that 
their value is increased, by the observations of Dr. Hodge of our city, 
who has prepared the paper for the "American Journal of Medical 
Sciences "for February, 1833, page 463. 

" It being generally acknowledged, that the child during parturition 
is much more endangered when it presents the pelvicihan the cephalic 
extremity of the foetal ellipse, the question as to the nature and cause 
of this difference is of importance. M. Baudelocque, jr., in a late 
communication to the Royal Academy of Medicine, maintains that 
the cause of death in pelvic presentations is always the sam,e, namely, 
the interruption of the circulation from the mother to the child ; and 
that the effects of this interruption are always the same, namely, a san- 
guineous congestion in the brain and liver, with or without effusion 



WHEN THE BODY OF THE CHILD IS DELIVERED, &C. 283 

at the base of the brain. He considers, therefore, the asphyxia and 
the apoplexy of new-born infants, to be two degrees of the same 
state, there being, in both, sanguine congestion of the brain and other 
interior organs. 

" The cause of the interruption of the circulation between mother 
and child, he refers exclusively to pressure on the cord by the body, 
but especially by the head of the child in the pelvis. 

" Founded on these views, he recommends two modes of procedure 
in cases where the head is retained after the delivery of the body ; 
and the child's life thus jeopardized. He proposes to divide the 
umbilical cord, and allow it to bleed; and then to excite respiration 
immediately, even while the head may be in utero. For this last ob- 
ject, he suggests the use of a long silver cannula, with numerous 
perforations, by means of which atmospheric air may penetrate into 
the uterus, and also of a shorter cannula, which may, when requisite, 
be introduced into the mouth of the foetus. In eleven infants, pre- 
senting the feet, the umbilical cord was divided as soon as the pul- 
sations became feeble, and before the head was delivered : the children 
were born alive. In three cases, the division of the cord was not 
made, and the children were born dead. The attempt to excite 
respiration was not made in either of the above cases ; but M. Baude- 
locque conceives it may sometimes be requisite. It may well, however, 
be doubted, whether respiration can possibly occur when the head is 
fixed, as the case supposes, in the superior strait of the pelvis. But that 
respiration may, under peculiar circumstances, occur, and even cries 
be elicited while the child is in utero, a point hitherto much disputed 
and generally denied, seems to be proved by an experiment of M. 
Baudelocque. In the case of a face presentation, after having punc- 
tured the membranes he passed a cannula into the mouth of the child, 
and inflated the lungs. He and his assistants, M. Martin, a physician, 
and Madame Chaumonot, a midwife, distinctly heard, for the space of 
a minute, the respiratory noise. The infant was eventually delivered 
alive by means of the forceps. 

" Giving all confidence to the facts reported by M. Baudelocque, 
it would seem that in some cases at least, it would be useful to divide 
the umbilical cord before the delivery of the head, to relieve conges- 
tion, and to prevent effusion and death. But, can these cases be 
always ascertained ? may not the child perish from the loss of blood, 
owing to the time required for the delivery of the head ? and especially 
is it necessary to inquire whether, as M. Baudelocque supposes, this 
congestion always exists? or whether, on the contrary, it be not often 
true that the child is already in a state of anemia, where the loss of a 
small quantiiy of blood would be necessarily fatal ? The questions 
also arise whether other causes may not be operative in the destruction 
of the foetus, independent of interruption of the placental circulation ; 
and whether such interruption depends on the pressure of cord, as 
has been usually supposed ; or, on some other circumstance, connected 
with pelvic presentations ? 



284 THE USE OF THE FORCEPS. 

" M. Hervey de Chegoin, in a report to the Academy, on the com- 
munication of M. Baudelocque, has noticed several of the above ques- 
tions ; and expressed his doubts on many of the positions assumed by 
the author of the essay. 

"In presentations of the inferior extremities, and, of course, in the 
operation of version by the feet, do not foetuses often perish in conse- 
quence of the force applied by the accoucheur, rather than by pressure 
on the cord ? M. Baudelocque and Madame Lachapelle would say, 
no ; because they have met with cases where great force had been ex- 
ercised, even to the tearing of the vertebral ligaments, and yet the 
child has survived. The reporter, however, doubts the legitimacy of 
the deduction, when the results of cases in which little or no traction 
has been exercised, are compared with those in which much force had 
been employed. Certainly few can doubt the injurious effects of trac- 
tion on the lower extremities and body, in cases where the head is 
retained, and the consequent danger to which the child is exposed ; 
especially when, as is not unfrequently the case, from ignorance or 
inattention, the neck is also twisted. The only wonder which can be 
excited is, that all do not perish under this management. Hence, as 
the effect of traction, when the head is entering or engaged in, the 
superior strait, is almost always injurious by causing the head to pre- 
sent unfavourably, the practice, however general or sanctioned by 
authority, should be abandoned : no force of any amount should, at 
this stage of the operation at least, be applied to the trunk of the infant ; 
but, if any resistance be required, it should be judiciously directed to 
the head itself. 

" There can be no doubt that M. Baudelocque is in error in refer- 
ring the interruption of the circulation between the mother and child, 
in all cases to pressure on the cord alone ; for as the reporter remarks, 
in pelvic presentations generally, after the trunk is delivered, the 
uterus has so contracted that a separation of the placenta from the 
uterus is very frequently effected; and in some cases, especially where 
the head has descended into the excavation, the uterus may be emptied 
not only of the child but also of the placenta. In all such cases, death 
must soon occur from the cessation of the placental functions, inde- 
pendently of pressure on the cord. 

" What is the result of compression of the cord? M. Baudelocque 
contends that in all cases the result is plethora, whence apoplectic 
congestion and effusion is demonstrated by dissection. But, says the 
reporter, this is a surprising assertion ; for if the pressure be made 
equally on the vein and on the arteries of the cord, the foetus, it is 
true, no longer sends blood to the mother ; but also no longer receives 
any from the mother by the umbilical vein. The exit of blood is pre- 
vented, but the supply is also cut off; therefore, there can be no in- 
creased quantity. M. Chegoin, however, carries this argument much 
farther, and contends, that as the circulation of blood in the vein is 
effected only by the agency of capillary vessels, while the passage of 
blood through the umbilical arteries is facilitated by the contractions 



WHEN THE BODY OF THE CHILD IS DELIVERED, &C. 285 

of the foetal heart, it follows that when the vessels of the cord are 
equally pressed upon, the course of blood may be arrested in the vein, 
but not in the arteries, where the momentum is greater ; in other words, 
that the exit of blood is continued while the supply is arrested. 
Hence, the foetus, instead of being plethoric, may actually perish for 
the want of blood, and this condition, M. Chegoin intimates, would 
be more likely to ensue when the placenta was separated from the 
parietes of the uterus. This apparently specious theory is supported 
by the well known fact, that children are born presenting externally 
very different appearances under the circumstances now contemplated. 
In some, the child is livid and swelled, particularly on the head, neck, 
and chest ; the cord is large and tense, and on being cut, the blood 
issues with much impetus. In others, the infant is pale and exhausted, 
its limbs flaccid, features contracted, cord small and pallid, and when 
divided furnishing little or no blood. The former is regarded as a 
state of apoplexy ; the latter as a state of anemia, of syncope, or 
asphyxia. 

We must, however, dissent from the idea of actual plethora or 
anemia in those cases where death suddenly occurs, the mother 
and child having been previously in a natural and healthy condition. 
Independent of many facts which might be adduced in opposition to 
these theories, both opinions seem to be predicated on an erroneous 
view of the fcetal circulation : viz. that the blood of the fcetus passes 
indirectly by means of the umbilical arteries and maternal veins to 
the mother, and the blood of the mother indirectly by maternal ar- 
teries and the umbilical vein tu the child; so that blood might be 
lost by the child from its arteries when the supply by the vein was 
arrested, whence anemia; or, that the supply might be continued 
from the mother while the exit by the arteries of the cord was 
diminished or suspended, whence plethora. But we thought that 
these views had been abandoned by good physiologists. There is 
satisfactory proof that there is no direct or indirect communication 
between the blood of the mother and that of the child. The latter 
forms its own blood in utero out of materials furnished by the 
parent, as certainly as the chick forms its own blood in ovo, out of 
materials there provided. The blood from the umbilical arteries of 
the child passes to the radicles of the umbilical vein, and not those 
of the maternal vessels ; and hence any variety of pressure on the 
arteries or vein of the cord can have but a comparatively trifling 
influence on the quantity of blood at any time in the body of the 
fcetus. 

"If, therefore, neither plethora nor anemia be the cause of death 
when pressure is made on the cord, whence the source of mischief? 
Very many have referred it to the simple interruption of the circu- 
lation, but this is not sufficient, as death occurs too suddenly to 
admit of this explanation ; and, moreover, the anatomical structure 
of the fcetus is such as to allow a perfect circulation of blood, even 
if the cord be completely obstructed. The injury, therefore, must 

25* 



286 THE USE OF THE FORCEPS, 

be referred to some other source, and as this death occurs suddenly, 
and is usually accompanied with great venous congestion, and may 
be prevented by establishing at once the respiratory process, it may 
be referred to the suspension of the purifying influence of the pla- 
centa on the blood, the placenta acting as lungs to the foetus — how 
is unknown. Hence, as congestion of venous blood follows the 
suspension of the respiratory process, congestion follows the sus- 
pension of the placental influence, and may be succeeded by the 
effusion of blood as testified by Baudelocque aud others. It is 
difficult, however, to account for the opposite condition of the foetus, 
or to specify the particular circumstances which produce a state of 
congestion or syncope. There are wanting a very careful ob- 
servation and collation of facts on this subject. But if it be true 
that children are born sometimes in the one, and sometimes in the 
other condition, the practice of dividing the cord in all cases of 
delay must be very dangerous, even should future experience con- 
firm the recommendation of M. Baudelocque in cases where con- 
gestion can be demonstrated to exist. 

"Again: should the hypothesis of the author be correct, that in 
all cases of asphyxia of new-born infants, there is congestion of 
some internal organ and often effusion, yet the practice he recom- 
mends must be injurious, as the general circulatory system is de- 
pressed and emptied. The local congestion, in such cases will not 
justify general depletion. Infants are often recovered from this 
state, not by depletory measures to which none resort, but by in- 
ternal and external stimuli which sympathetically excite the respi- 
ration and circulation. 

"It is a difficult matter to determine, by external appearances, 
the precise condition of the internal organs in this asphyxiated 
condition of new-born infants. Baudelocque insists that congestion 
always exists, and often effusion, and appeals to his dissections, 
where such changes were invariably perceived ; but the condition of 
the organs after death, as regards their vascular fullness, is no 
certain index of their state before death ; and, as infants born in 
this state of asphyxia are frequently preserved by judicious and 
persevering efforts, we must conclude that such congestion and effu- 
sion either do not exist, or that they are less injurious than usually 
supposed ; and moreover, that stimulating, not depletory measures are 
suitable in such supposed cases of congestion. 

"As to the apoplectic state above described, all will unite in the 
importance of evacuating the blood — a practice commonly resorted to, 
and which may be employed as M. Baudelocque recommends, even 
before the delivery of the head. An additional remark, however, is 
of importance, that this depletion should be followed up by stimuli to 
the surface, nostrils, rectum, &c, as in cases of asphyxia ; for the ac- 
tions of the heart and arteries are feeble, and the surface cold in these 
apoplectic cases, evincing depression of arterial action with the fulness 
and turgescence of the venous system. Hence, while we empty the 



WHEN THE BODY OF THE CHILD IS DELIVERED, &C. 287 

veins, and blood should be determined to the arterial system, that the 
natural actions may be fully re-established. 

" On the whole, we agree with the reporter, M. Chegoin, that death 
in pelvic presentations is not simply the result of pressure on the cord, 
but may also ensue from other causes, as injury to the spinal marrow; 
detachment of the placenta, &c. ; that general plethora does not exist 
when such interruption occurs ; neither, we would add, is there any 
deficiency of blood in the foetus ; and that in a practical point of view, 
the states of asphyxia and apoplexy are so far different, that in one 
the loss of blood would be injurious, but in the other highly useful. 
We believe, however, that these cases are so far of the same character, 
that, in both, the arterial circulation is depressed ; of course, the phe- 
nomena of organic life diminished. The one condition may be re- 
garded as a simple state of asphyxia, the other as asphyxia with venous 
congestion of the vital viscera ; the one requiring simple but appro- 
priate stimulation, the other in addition, evacuation of venous blood 
to relieve oppression and facilitate reaction of the heart and arteries." 

901. These considerations early engaged the attention of Smellie ; 
and the result of his deliberations was, the practicability of applying 
the forceps with success in such cases. Accordingly, he has left upon 
record his method of employing them, and the success attending it. 
He has been followed by De Leurie, Baudelocque, and others. I am 
every way disposed to do justice to the merit of this application of 
the forceps ; and consider it as a real improvement in the art, when- 
ever their application is guided by experience, or their employment 
properly limited. 

902. It will be readily admitted, by all who have attempted the ap- 
plication of these instruments, with a view 7 to relieve the head when 
the body was delivered, that it is attended with no inconsiderable dif- 
ficulty, even in the most simple of the cases in which they may be 
required ; how much more, then, when the head is remote from the 
inferior, and perhaps tightly wedged in the superior strait ; in both of 
which cases the use of these instruments is recommended. I did not 
succeed in the two or three instances in which I employed them, 
under the circumstances described by Smellie and Baudelocque, and 
as represented by the former in his 35th, and by the latter in his 14th 
plate. I will not say that their application is impracticable because I 
failed ; especially as both Smellie and Baudelocque declare they have 
succeeded ; but there are several serious difficulties to oppose their 
application, which I will endeavour to point out : 1st. When the head 
of the child is at the superior strait, and engaged with its greatest 
length between the pubes and sacrum, or even w r hen the forehead 
and vertex offer to the sides of the pelvis ; as the axis of this strait 
is so much in advance of the inferior, that it seems almost impos- 
sible that the perinaeum could be pressed so far back, as to permit 
the forceps to correspond with it, that they may securely grasp the 



288 CASES PROPER FOR THE FORCEPS. 

head ;* 2d. That if the head be even grasped by the forceps, it must 
be in the direction, or very nearly so, of the perpendicular diameter 
of the child's head, instead of the oblique ; a circumstance of great 
consequence to the success of the operation ; 3d. This advantageous 
position of the head for the use of these instruments, may lead to the 
belief that they are well placed, because their handles unite ^without 
difficulty ; whereas, they but very partially embrace the head ; and if 
an effort be made to extract, they will most probably slip, and the 
uterus, vagina or bladder be severely injured. 



Sect. I. — Cases proper for the Forceps. 

903. From these considerations, I would confine the use of the for- 
ceps, in the cases under consideration, to two situations of the head, 
and those at the inferior strait, a. The first when the vertex is behind 
the symphysis of the pubes, and the face resting on the face of the 
perinseum ; b. The second when the forehead is behind the symphysis, 
and the vertex lying towards the hollow of the sacrum. 



a. Mode of Operating in the First Case. 

904. It rarely happens that the forceps are indicated in this situation 
of the head, since, when it arrives here, it may be almost always de- 
livered by soliciting the voluntary powers of the woman ; by depress- 
ing the chin; and by a judicious force exerted upon the trunk. But 
at this moment, the woman may be attacked by some accident ; or the 
head may be very large, or the pelvis narrow ; the cord may be in 
danger of compression ; the woman may be too feeble to make any 
effort to relieve herself and it might require too much force for the 
safety of the child to attempt its deliverance by the body alone, yet 
the w r elfare of it may require immediate delivery. 

905. When the circumstances of the case will most probably be 
improved by the use of these instruments, we should apply them, if 
at hand, without loss of time,f in the following manner ; the body of 

* This will be readily understood, when it is recollected, that the direction of the 
opening of the superior strait is at an angle of about 30°, and, consequently, i's 
axis, and that of the inferior strait, do not coincide. 

t It might, on some accounts, be proper to be provided with these instruments, 
whenever we have leisure to send for them, in all such cases as we cannot decide 
positively that they will not be necessary. I was once made very happy by having 
them with me, when sent for to the aid of a midwife. The patient was pretty far ad- 
vanced in life before she married ; she had lost three children previously, and was now 
in labour with a breech presentation, The child was very large, and required the fillet 
— the breech I delivered, the body followed, and no difficulty was experienced until 
the head was stopped at the inferior strait, in consequence of its size. I employed as 
much force as I dared, and the woman exerted herself powerfully ; but the bead though 
well situated, could not be made to pass. I was very anxious about the life of the 



OF THE PRESENTATIONS OF THE FEET. 289 

the child must be carefully wrapped up in a cloth, and carried over 
the mons veneris, as far as it can be done, without injury to its neck, 
and supported there by a careful and judicious assistant ; the chin of 
the child should be depressed, and the male branch of the forceps 
be passed to the left side of the pelvis, depressing the handle pretty 
suddenly against the perinaBum: this must be more or less, as we may 
find it necessary to make the blade conform as much as possible to 
the oblique diameter of the head : when this is arranged, the handle 
must be sustained until the other blade is passed on the opposite 
side of the pelvis, and made to correspond with its fellow — the han- 
dles must now be locked, and drawn in such direction at one and 
the same time, as shall tend to disengage the vertex from behind 
the pubes, and at the same instant raise the face along the perinaeum, 
until the chin and other parts of the face successively pass through 
the os externum. 



b. — Mode of Operating in the Second Case. 

906. The only difference in the mode of operating in this case 
from the first, (905,) is, that the body of the child must be carried 
backward, and gradually depressed as the head disengages back- 
ward.* 



CHAPTER XXVIII. 



OF THE PRESENTATIONS OF THE FEET.f 

907. The presentations next in the order of frequency, are those 
of the feet; these presentations are with propriety ranked among the 
natural labours, because the woman is enabled to deliver herself. 
Baudelocque says that " those labours in which the child presents 
the feet, considered as natural, are not the most advantageous; but 
as preternatural, they must be esteemed the easiest and the most 
favourable." In this I cannot exactly coincide, at least as far as 
regards the safety of the child, which, in my opinion, ought always 
to enter into the calculation; for its welfare must be looked upon as 

child, and the poor mother begged that I micht save it at any expense of pain to her- 
self, as s ; ic, " had lost all her poor babes before." I determined to try the forceps, as 
I had brought them with me, and dirl with the happiest effect. 

* Bnidelocque advises the forceps in these cases, when the child is dead, instead of 
the crotchet. 

t Of twenty thousand, five hundred and seventeen births, there were 234 feet pre- 
sentations : of the 1st, 135 ; of the 2d, 86. 



290 SPECIES OF FEET PRESENTATIONS. 

constituting at least a part of what is to be understood by the words 
" most favourable." I have elsewhere, (858,) assigned my reasons 
for this. 

908. Had not the erroneous principle been so often inculcated 
and still more frequently acted upon, " that in presentations of the 
feet, not to deliver the woman as speedily as possible, was, to exer- 
cise a cruelty towards her, by permitting her to endure hours of pain, 
when it was in our power to relieve her in a very short time, by ex- 
erting a force by the feet, which would speedily deliver the body," 
we should have had fewer instances to complain of injuries sus- 
tained by the mother, and fewer occasions to lament the death of the 
child. 

909. It should be held as a fundamental principle in this variety 
of labour, and all the others enumerated under the title of natural, 
that they must be considered as such in the true sense of the word, 
at least until the uterus is dilated, aud the membranes are rup- 
tured, and after these have taken place, only to consider them as 
preternatural, or labours, requiring assistance, when they are compli- 
cated by accidents, or when their progress is retarded by causes ex- 
isting in the uterus itself, or from the position of the child. Under 
such circumstances, we are not only justified in aiding the woman in 
her struggles, but it becomes a duty to do so, in the best and most 
efficient manner the case will admit. But to do this with the great- 
est advantage to both mother and child requires a thorough know- 
ledge of the mechanism of these labours, as well as considerable ad- 
dress to fulfil the various indications their different positions create ; 
that the former need not suffer from the effects of ignorant rashness, 
or the latter fall a victim to it. 

910. The presentations of the feet are readily distinguished from 
all others, by there being no other parts of the child which resemble 
them ; the hands alone bear any analogy ; but from them they are 
easily told by the projecting heels, the short toes, and especially by 
the absence of the thumb. Baudelocque, whom I shall follow, has 
divided presentations of the feet into four species — the distinguishing 
marks of each being derived from the part of the pelvis to which the 
heels and toes are directed ; accordingly, four species are made. 



Sect. I. — Species of Feet Presentations. 

911. In the first presentation, the heels are a little anterior to the 
left acetabulum, and the toes are directed towards the right sacro-iliac 
symphysis ; the breast and face are above and over it, while the 
back is placed to the anterior and left lateral part of the uterus. It 
may, perhaps, be proper to remark, that in these presentations, the 
feet and legs do not hang loose or dangle in the pelvis, but, on the 
contrary, the thighs are flexed against the abdomen, the legs folded 
against the thighs, while the heels are almost always placed against 



PRESENTATION OF THE FEET. 291 

the breech, or are in its immediate vicinity. I thought it best to state 
this, that the difficulty which is sometimes experienced in bringing 
down the feet may be better comprehended. It must be also borne 
in mind, that both do not always present at the same time, and that 
they are so moveable in the pelvis oftentimes, that it is more difficult 
to locate their exact position, than to distinguish it is the feet that are 
presenting. 

912. In the second presentation, the heels are behind the right 
acetabulum, or a little forward ; the toes look towards the left sacro- 
iliac symphysis ; while the breast and face are above and over it : 
the back is placed to the right anterior portion of the uterus. 

913. In the third presentation, the heels are to the symphysis pubis, 
and the toes towards the sacrum ; the back is placed to the anterior 
part of the uterus, while the breast and face look towards the lumbar 
column. 

914. In the fourth presentation, the position of the child is exactly 
reversed : the heels are to the sacrum, and the toes to the pubes ; the 
back towards the lumbar column, and the breast and face are turned 
towards the anterior part of the uterus. 

915. Nature seems to have been particular in the arrangements 
of the presentations of the breech, feet, and knees, by making the 
numerical order of each resolve themselves into one general posi- 
tion, so soon as the legs are without : so that the most favourable 
situation, or the first presentation of the breech, of the feet, and the 
knees, have each of them the legs in precisely the same situation 
when delivered : so true is this, that did we not arrive, before this 
happened, we could not tell with which of these presentations the 
labour commenced — the same may be said of all the rest. We are, 
therefore, much indebted to Baudelocque for his ingenious and na- 
tural arrangement of these labours. It is also remarkable that the 
frequency or infrequency of each of these different species of natural 
labour should be, with few exceptions, in the order of their nume- 
rical succession ; thus, the first presentations of the breech, feet, and 
knees, are more frequent than the second ; the second more frequent 
than the third ; and this third more frequent than the fourth, &c. 

916. Why is it that we meet with more presentations of the feet 
in premature deliveries, than in those at full time ? or, is it only co- 
incidence ? 



Sect. II. — Preternatural Labours in which the Child presents the Feet. 

917. The causes which may render a labour preternatural, in which 
the child presents the feet, may be any of those already enumerated, 
(651 :) or it may depend upon some irregular and inefficient action of 
the uterus, or the mere position of the child itself. Should either of 
these accidental causes complicate a labour in which the child pre- 
sents the feet, we must consider it a sufficient reason for interfering 



292 FIRST AND SECOND PRESENTATIONS. 

with its progress ; and we must expedite the delivery by bringing 
down the feet; the mode, however, of doing this will depend upon 
the particular presentation we may have to contend with. 

918. From the position which the feet almost always assumes in 
these presentations, it will be readily perceived, that one cannot well 
descend without the other, and that it is the width of the breech, 
thighs, and legs, which offer together at the superior strait ; hence, 
they will sometimes become jammed at this part, and the feet, or a 
foot, will cease to advance, and as this may happen, and the diffi- 
culties of the labour arising from this may be increased, by some one 
of the accidents already enumerated (651,) they give sufficient reason 
for manual interference. Or the uterus may, from any of the causes 
we have already acknowledged to be capable of such effect, be in- 
competent to force the parts down to the bottom of the pelvis, though 
no embarrassment be created by position. Or the fourth presentation 
itself may be considered as essentially bad, and require our inter- 
ference. 

919. Under either of these circumstances, we are obliged to convert 
an otherwise natural, into a preternatural labour. It will be constantly 
kept in mind, when taking hold of the feet is recommended, it is al- 
ways supposed that the membranes have been ruptured, and the os uteri 
dilated, as has been uniformly inculcated for every operation of the 
kind. It may be remarked here that there will be some difference 
in the mode of acting in footling cases, arising from the circumstance 
of presentation, or of one or both feet being within reach; but these 
will be illustrated as we proceed. We will repeat, lest it be forgotten, 
that the woman is supposed to be constantly placed upon her back as 
recommended for all cases of preternatural labour. 



Sect. III. — Mode of acting in the First and Second Presentations 

of the Feet. 

920. It has already been remarked, that in both these presentations, 
when the feet are without the vulva, that the mechanism is the same 
as the first and second breech presentations ; therefore I shall only 
point out the mode of treating the labour until that period ; for after- 
wards, every thing must be conducted as directed for those presenta- 
tions. 

921. "When it is agreed that there is a necessity to expedite the 
labour, it must be done by introducing the hand into the vagina, if 
the feet still remain at the superior strait ; if this be the case, we pass 
the hand until we can by a proper grasp possess ourselves of them ; 
and, when secured, we draw them downward; but, if this require 
more force than it would be prudent to exert, we must desist, and 
act upon the breech, by gently raising it upwards: this will almost 
always permit the feet to fall down ; or, at all events enable us to 
proceed with them through the pelvis. Should but one foot offer, 
we may act upon it, and oftentimes successfully, when the child is 



THIRD AND FOURTH PRESENTATIONS. 293 

small compared with the size of the pelvis ; but if it come reluctantly, 
and evidently requiring a considerable degree of force to bring it 
along, we should cease to act upon it, and search for the other foot. 

922. When the second foot is accessible, it is always best to make 
it descend with the first ; and not merely push it up that it may un- 
fold itself along the abdomen of the child. But let it be recollected, 
when we are obliged to search for the second foot, it is a matter of 
consequence to make a proper choice of hand ; for it may be resting 
on the margin of the pelvis, or it may be unfolded and high up in 
the uterus ; therefore, in either case the facility of the operation will 
very much depend upon the hand that is employed — this I well know 
from experience. The rule in these cases is precisely the same as for the 
breech cases of the same numerical denominations ; namely, the left 
hand for the first, and the right hand for the second presentation, &c. 

923. The reasons wherefore I prefer having both feet to act upon 
in these cases are, — first, we can exert the necessary force to much 
greater advantage by acting with both ; secondly, we run much less 
risk of doing injury to die limbs ; for if we act by one alone, w T e may 
chance to hurt it by the force not being divided; thirdly, we can 
give a better direction to the body as it descends ; w r hen it is neces- 
sary to effect any change upon its course. 

924. The only difference in the mode of acting in the second pre- 
sentation and the first, is the necessary choice of hand — in every 
other respect the mechanism is the same. 

925. Should more than two feet be found in the passage, as in 
twin cases, we must be careful to select those which belong to the 
same child ; this sometimes creates more difficulty than w r ould at first 
be imagined ; for simply selecting a right and left foot, by no means 
proves they belong to the same body ; and if they should not, 
much inconvenience may be experienced. It is true, this circum- 
stance will rarely occur, as it seldom happens that the membranes of 
both give way at the same time, or before one of the children is de- 
livered ; yet it happens sufficiently often to make the caution neces- 
sary. An instance of this kind occurred to me some years ago : for, 
in attempting to bring down two feet, (properly selected, as I sup- 
posed,) where there were three, I got a foot of each of the children : I 
discovered my mistake, however, sufficiently early to enable rne to pass 
up ray hand, and select the proper foot, but not without some diffi- 
culty. 



S::ct. IV. — Method of Acting in the Third and Fourth Presentations 

of the Feet. 

926. Were I permitted to draw a conclusion from my own experi- 
ence, or take for fact what is stated in the register of " PHospice de 
Maternite," either of these presentations would be found to be ex- 
tremely rare, and especially the last. Of the third presentation, I find 
*26 



294 THIRD AND FOURTH PRESENTATIONS. 

but three instances recorded in nearly thirteen thousand cases, in the 
practice of that institution, and of the fourth but one. In examining 
my own practice, I find two of the third, and but one of the fourth 
presentation. 

927. The third presentation is not so replete with inconveniences 
as the fourth, nor so uniformly fatal to the child ; yet they are suffi- 
ciently so, to make us fear when it occurs, especially if the forehead 
does not spontaneously turn from the projection of the sacrum, and 
place itself before the sacro-iliac symphysis of one side or other 
of the pelvis, that the head may descend in a diagonal situation to the 
lower strait — when it arrives at this place, and in this direction, it will 
rarely happen that the face cannot be made to apply itself to the peri- 
neum at the last period of labour. 

928. Should this favourable disposition of the head, however, not 
take place spontaneously, it points out what should be done to make 
the labour more advantageous to both mother and child. Should we 
have charge of the case sufficiently early, that is, before the feet 
have descended, and when the membranes have but lately yielded, 
we may dispose the head to turn to one side, by making the body 
observe an oblique position in its descent, by turning the toes to one 
side of the pelvis. Indeed, this would seem to be almost the only 
period at which we could pretend, with any certainty of success, 
to do this, by any manoeuvre performed on the body of the child ; 
for after it is either in part, or wholly delivered, they would be al- 
most nugatory. 

929. We are directed by most writers who have mentioned this, 
and the fourth presentation, to attempt this change, by giving an ex- 
tensive twist to the body. Thus, La Motte, Levret, and Smellie, 
advise this motion to be made, by turning the child's body, under the 
expectation that the head and face will obey the impulse, without 
seming to recollect that in these cases the head is not very moveable 
in the pelvic cavity ,* especially when the waters have been long 
drained off; and that to change it would require much more force 
than can be safely exerted, or a much more extensive twist of the 
child's neck than would be compatible with its safety. 

930. When the body is delivered, and the shoulders have de- 
scended sufficiently low to permit it, we should immediately as- 
certain whether the position of the head be correct or not — should 
its position be favourable, we proceed with the labour, as has been 
already directed for the breech ; should it not, we must endeavour to 
rectify it, by acting upon the face so soon as the shoulders have been 
cautiously delivered ; that is, without having exerted a force upon 
them, sufficient to jam the head in a bad direction at the superior 
strait. 

931. Should the head be jammed in the superior strait, by any 
ill-directed force, it must be relieved as quickly as possible, if we 
expect to preserve the child — this must be done, by passing the hand 
under the head at the bottom of the pelvis and gently raising it, so as 



THIRD AND FOURTH PRESENTATIONS. 295 

to lift the vertex from behind the pubes, and at the same time turn 
the face to one side. The side to which the face must be turned, 
will depend, first, upon the inclination it may have to either the right 
or left side ; choosing that always to which it most tends ; and, 
secondly, upon the hand which may be employed to rectify the po- 
sition, when no inclination toward one side or the other is observed ; 
if the right hand be used, it will be easiest, caeteris paribus, to turn 
it towards the left, and the reverse. 

932. Before, however, this reduction is attempted, it will be well 
to have the body of the child carefully raised by an assistant, towards 
the abdomen of the mother, that the hand may be introduced with 
more certainty and facility ; care being taken in doing this, that the 
head is not drawn down, by the body being carried up. When the 
position of the head is adjusted, we must act as has been directed 
in such cases for the breech. 

933. In the fourth presentation, we can scarcely expect to im- 
prove its position, unless we are very early with the patient; that is, 
immediately after the yielding of the membranes, and have, at the 
same time, the os uteri sufficiently dilated to enable the child to obey 
the direction we mean it should take. Unless we can take ad- 
vantage of this period to move the face toward one of the sides of 
the pelvis, I am disposed to believe that very little can be done until 
the shoulders are without — except, indeed, the head be small com- 
pared with the pelvis ; in this case, there is very little necessity for 
assistance, as it will pass, face upward, under the arch of the pubes, 
without much difficulty. 

934. When the shoulders are without, I am sure it will sometimes 
succeed, to turn the face towards one of the foramina ovalia ; the 
occiput, by this change, will descend a little, and offer itself towards 
one of the tubers of the ischia, or a little obliquely as regards the 
lower strait ; and may, by a well directed force, aided by the volun- 
tary contributions of the mother, be made to escape in this diagonal 
position. 

935. I would always recommend to the young practitioner, in 
cases of such very doubtful issue to the child, and more especially in 
the fourth presentation, to advertise the friends of the patient of the 
risk the child must inevitably run in its delivery; that no exorbitant 
hopes may be entertained of its eventual safety. 

936. There will be of course, the same propriety in using the for- 
ceps in any of these cases, as was expressed for their employment in 
breech cases. 



296 



PRESENTATIONS OF THE KNEES, 



CHAPTER XXIX. 



PRESENTATIONS OF THE KNEES. 



937. The presentations of the knees are very rare indeed ; and I 
might, perhaps, have passed them over in silence, without incurring, 
much censure for the omission. But I have chosen to notice them, 
because they are rare; and because they are sometimes embarrassing 
to the young practitioner ; for I well recollect my own trepidation, 
when called to a case of this kind in the very commencement of my 
practical career. To add to my embarrassment, I was called to the 
assistance of a midwife, who could not well have been more ignorant 
of what was proper to be done than myself. I will not pretend at this 
time to designate the particular presentations of the knees, as I knew 
nothing about their presentations at that time ; I only recollect, that I 
reasoned in the following manner upon the subject : — "If the feet were 
without, I should feel little or no difficulty in the case, as I once at- 
tended a labour of this kind successfully ; and it cannot be very 
dangerous to pass the hand to them, since they must be in the neigh- 
bourhood of the knees." With these reflections, I passed a hand into 
the vagina, and tracing the legs, soon obtained the feet, which I had 
the good luck to bring along, by accidentally, (for so it was, as I had 
no principle to direct me,) disengaging the knees from the margin of 
the pelvis, against which I now know they must have butted, and ter- 
minated the labour successfully to both mother and child, but with 
severe agony to myself. 

938. These presentations are more unusual than any I have hitherto 
considered ; not occurring oftener, perhaps, than once in a thousand 
or more times. They are less favourable than any of the presentations 
I have classed as natural; and agreeably to Baudelocque, they may 
present in four ways : 

939. In the first presentation of them, the legs are to the left side 
of the mother, and the thighs to the right. 

940. In the second, the legs to the right, and the thighs to the 
left. 

941. In the third, the legs under the arch of the pubes, and the 
thighs tuvards the sacrum. 

942. In the f jurth, we find a reverse of the third. 

943. The mechanism of these labours is precisely the same as those 
of the feet; for the latter must be quickly developed, if the labour 
proceed ; and then they are reduced to footling cases. 

* Of 20,517 births, there were only four of the knees. I have seen three presenta* 
Ifcions of the knees, in about 10,500 births. 



PRESENTATIONS OF THE KNEES. 297 

944. The knees may be distinguished, when together, by their si- 
milarity, and the roundness of the bony angles they form. When 
but one presents, which is most commonly the case, it is not so easy ; 
but we may trace the leg, and find by this means the foot, which puts 
the matter out of doubt. 



Sect. I. — Causes which may render Presentations of the Knees 'pre- 
ternatural. 

945. Until the membranes be ruptured, and the uterus properly 
dilated, a presentation of the knees, if the presentation can be dis 
covered before that period, is to be treated as has been directed foi 
the breech or the feet. 

946. Baudelocque directs that we should not search for the feet in 
these presentations, unless the labour be complicated by some acci- 
dent ; but the difficulties which a woman almost always experiences 
in delivering herself in these cases, are such as to render it, I think, 
the better practice always to bring down the feet; especially in the 
earlier part of the labour, when neither force is required, nor incon- 
venience hazarded, by the proceeding. I once witnessed a case 
where many hours of severe suffering had been endured, from a pre- 
sentation of the knees, without its having made the smallest progress, 
after the first hour or two : the breech and knees had progressed to- 
gether in such a manner as to completely occupy the pelvis; several 
pretty severe attempts had been made by the midwife, as she herself 
declared, to make the knees descend, by acting upon them to the 
serious injury of the child. After this period I was requested to visit 
the patient. I found the presentation to be the first ; but the breech 
had descended so much as to carry the knees against the right sacro- 
iliac symphysis, and thus prevented the farther progress of the labour. 
I introduced the right hand, and with some exertion was enabled to 
raise the breech sufficiently to permit the feet to fall down near to the 
os externum ; the knees were then readily removed form their position, 
and the delivery speedily effected. 

947. Now, as there is no security that the breech will not descend 
in proportion to the advancement of the knees, and if it do, the knees 
will almost certainly be arrested against some portion of the pelvis, in 
which case the contractions of the uterus and the efforts of the woman 
are almost sure to be unavailing, though continued for hours, I think 
it always best to bring down the feet and knees, by pushing up the 
breech, whether the case be free from, or complicated by any of the 
accidents already mentioned ; unless the os uteri is sufficiently dilated,, 
and the feet are found to unfold, or the knees to advance : in this case 
we rcav trust the labour to nature. 



£9$ OF TEDIOUS LABOUR. 



•Sect. II.- — Mode of Operating in Presentations of the Knees. 

'948. When we attempt the relief of the woman in such cases we 
should commence as early as the state of the uterus will permit, and 
'especially, when it may be either the third or fourth position ; in 
either of which we Should experience all the inconveniences which 
are found in the third and fourth presentations of breech and feet, 
"with the contingency of the knees stopping in their progress ; and this, 
&t a time when it might be either difficult or dangerous to attempt 
■making the changes upon the direction of the body, so important to 
the safe delivery of the head. 

949. Baudelocque recommends pushing up the knees when we 
attempt their reduction ; but, so far as I am capable of comparing the 
'.two methods, I think acting upon the breech is the better plan. 

950. He also advises the employment of the fillet, or blunt hook, 
Ifor the delivery of the knees — I confess I have tried neither — but it 
appears to me they cannot, in every position of the knees be employed 
^vvith advantage ; but in one I think they may aid, (that is, the fourth,) 
"when these parts have descended low in the pelvis ; as then the di- 
rection necessary to the delivering them will be the one, and the 
•only one, we can give them by either fillet or blunt hook. The pro- 
per hand must be employed when we attempt to raise the breech, or 
^we may fail in the attempt to liberate the feet and knees — in the first 
presentations we must use the right hand,; in the second, the left; 
;and in the third and fourth, either. 



CHAPTER XXX. 



<OF TEDIOUS LABOUR. 



r 9'51. Many causes have been assigned for tedious labour ; some of 
%vhich are sufficiently evident ; while others are extremely obscure, if 
mot altogether inscrutable. The causes have been divided into con- 
stitutional and local ; both of which unquestionably may exist, but 
the former is much more rare than the latter. The general, or consti- 
tutional causes appear to consist almost exclusively in passions, or 
emotions of the mind ; or, at least, to some peculiar condition of the 
sensorium commune, and nervous system. Thus, w T e see uterine 
action rendered feeble and transitory for many hours together, or sus- 
pended from half an hour to a number of days, from the influence of 
some unexpected or distressing intelligence ; or, sometimes even, the 



OF TEDIOUS LABOUR. 299 

presence of a strange accoucheur (259) or midwife, will have the same 
effect. 

952. The state of the muscular system, appears to have but little 
influence upon uterine contraction : for when it exists in its most 
healthy condition, it by no means ensures the best efforts of the ute- 
rus ; nor does a state of almost exhaustion, necessarily interrupt the 
regular and successful play of this organ. 

953. Nay, we may go farther, and declare that the functions of the 
uterus; are in very many instances, never more rapidly, or success- 
fully performed, than when the powers of the muscular system are be- 
low the natural standard of health, or even, indeed, when they are 
much reduced. Thus in the last stages of fever, or of phthisis pul- 
monalis ; or, in a word, any other exhausting disease, the uterus, at 
the proper time, is almost sure to discharge its contents, not only 
with rapidity, but almost without pain. Here the relaxed condition 
of the soft parts immediately concerned in the act of delivery, cease to 
oppose the contractions of the fundus and body of the uterus ; and this 
organ itself seems to be so economical of its powers, as not to surfer 
their waste, even when all the other muscles of the body are rapidly 
yielding them. Here, the os uteri gives way with instant and seeming 
willingness, to uterine contraction, and will not oppose by obstinacy 
as in most cases, the passage of the child, and render labour tedious. 

954. In general, the condition of the os uteri (caeteris paribus) may 
be looked upon as one of the surest guides to determine the duration 
of labour ; and hence, when it is not disposed to yield,* it becomes 
the most common cause of tedious labour; and hence we may learn 
why the local cause or causes are much more frequent in their ope- 
ration than the constitutional. Among these we may especially 
reckon — 

1. A want of contractile force of the uterine "fibre. f 

2. A rigid condition of the soft parts concerned in labour ; espe- 
cially the mouth of the uterus itself. J 

3. Cicatrices, or other imperfections, arising from injuries done to 
the parts concerned. § 

4. A premature escape of the liquor amnii. 

5. Over- distention of the uterus producing torpor or inertia of this 
organ, and too dense a condition of the membranes. || 

* Without this the pains are of very little value; (hey worry the woman without 
benefiting her— ^he become exhausted by their frequency and force; for it is not a 
mechanical operation, as we have had frequent occasions to remark. When there is 
a secretion of mucus, and that plentiful, then the pains begin to be efficient, not by a 
mechanical stretching, but by another important link of the chain being now added ; 
for now the os uteri begins to yield. Before this takes plac', nothing is experienced 
but pain and disquietude ; but after the suffering begins to abate, and the parts to re- 
lax, the whole system is much quieted, and the labour found to advance. 

t See Chapter on Ergot. 

t See Section on Rigidity as a cause of Tedious Labour. 

§ See Section III. |l See Section V. and VI 



300 OF THE WANT OF CONTRACTILE FORCE. 

Of these we shall treat pretty fully, and illustrate the operations of 
each cause by appropriate examples. 



Sect. I. — Of the Want of Contractile Force. 

955. This is a condition of the uterus, and not an extremely un- 
frequent one, in which neither of the other enumerated causes are 
present, and for which it would be very difficult to assign the true one. 
It may, however, arise from some original defect of the uterine fibre, 
as it is occasionally found to be habitual with some women ; or it 
may follow the over-action of this organ. In the cases under con- 
sideration, we have not to contend with any unfavourable condition 
of the soft parts ; for the defect seems to be seated in the uterine fibre 
itself. And it is in such cases, that the ergot or secale cornutum, has 
been found so highly useful. See Chapter on Ergot. 

956. I shall relate a few cases, by way of illustration, of each of 
the conditions of the uterus just named. 

a. Where the powers of the uterus were partly exhausted by long- 
continued action. 



Case First. 

1817, Dec. 21st. I was requested to visit Mrs. , in consulta- 
tion. She had been in labour sixteen hours, with a first child, and 
was twenty- eight years of age. The waters had discharged them- 
selves early in the labour ; the pains had been, up to a certain period, 
strong and frequent ; the head had passed the os uteri, and every ex- 
pectation was entertained, for some time, that the labour would have 
terminated promptly ; but in this the medical attendant, and the friends 
of the patient were disappointed. 

The head occupied the inferior strait, and the vertex was applied 
nearly fair to the arch of the pubes. For some time the pains con- 
tinued to be frequent, but feeble ; but eventually, they nearly subsided 
altogether. After waiting, with things in this condition, for six hours, 
without the smallest advantage, I was requested to visit the patient. 

I found the lady suffering much from a generally spread pain over 
the abdomen ; some fever ; great restlessness ; pains nearly gone, and 
very inefficient ; and the head about to emerge from under the pubes. 
I soon perceived that the uterine forces were totally inadequate to 
depress the parietal protuberances below the tubers of the ischia. 
We, however, waited twenty minutes more to ascertain the absolute 
power of the pains, and during each, attempted to aid it, in the adap- 
tation of the vertex to the arch of the pubes ; that is, I assisted to turn 
the face exactly into the hollow of the sacrum. By this change in the 
position of the head, some advantage was gained, as it necessarily 
diminished resistance ; but it did not enable the uterus to accomplish 



OF THE WANT OF CONTRACTILE FORCE. 301 

the labour. By this time the patient could hardly be said to have 
pains. 

I now proposed to give our patient twenty grains of ergot: this was 
acceded to, and it was administered to her immediately. The first 
dose of the ergot evidently roused the dormant powers of the uterus ; 
and a second, of the like quantity, enabled it to expel a very large 
healthy child. 



Case Second. 

1818, May 30. I was called at eight o'clock, P. M., to Mrs. , 

the mother of several children ; she was constitutionally delicate and 
nervous. Her pains were weak, and returned only at long intervals, 
sometimes not recurring oftener than once an hour. On the 31st, at 
eight o'clock, A. M., I made an examination for the first time ; found 
the os uteri dilated pretty considerably, and very yielding ; pains still 
very slow. During a pain I gently stretched the mouth of the uterus, 
with a hope it might excite a stronger action in the body and fundus, 
but without advantage. As the parts w 7 ere all favourably disposed, I 
ruptured the membranes ; this also failed to excite contractions of a 
better quality. At two o'clock, P. M., I gave twenty grains of the 
secale cornutum, and repeated it in fifteen minutes : pains now suc- 
ceeded each other so rapidly and forcibly as to deliver the child safely 
in fifteen minutes more. 

No case can better decide the influence and specific action of the 
secale cornutum than the one just related. It most strikingly exhibits 
the superiority of this drug over the rupturing of the membranes, though 
this operation is one which often succeeds. We are aware that the 
practice of rupturing the membranes is condenmned by some, under 
almost any circumstance ; but, in doing this, I had an expectation, 
first, that by taking off the distending cause from the uterus, it would 
assume its usual powers, as not unfrequently happens when the waters 
are removed, by the unequal surface presented by the child, proving 
a stimulus to this organ ; and secondly, and particularly, that the tonic 
contraction would so certainly take place, as to secure my patient 
against a subsequent hemorrhage. 

b. Where a want of power in the longitudinal fibres of the uterus 
appeared to be the cause of the delay of delivery. 



Case Third. 

1819, May 26th. I was called to Mrs. , in labour with her 

sixth child. She was attacked with pain twenty-four hours before ; 
they had augmented gradually, but were very irregular in their recur- 
rence, though very severe. The os uteri Vas found pretty fully di- 



302 RIGIDITY, &C. OF THE SOFT PARTS. 

lated ; the head of the child was at the superior strait, and resting 
upon the pubes, in consequence of a pretty extensive anterior obliquity 
of the uterus. Things continued in this posture until two o'clock, 
P. M., of the 27th. I now ruptured the membranes, hoping it might 
increase the contractions of the uterus, or give them more efficacy ; 
for though the pains were very severe as regards sensation, they 
manifested very little propulsive power. 

The rupturing of the membranes was not followed by the slightest 
advantage ; I therefore determined on giving the ergot ; a scruple 
dose was accordingly given. It may be proper to remark, that, up to 
this moment, the head had not advanced a line. In fifteen minutes 
after the ergot was given, the pains became powerfully propulsive, 
and in a quarter of an hour more, my patient was safely delivered of 
a fine healthy boy. 

957. This case, like many others, decidedly shows the influence of 
ergot upon the uterus ; but perhaps it declares, in an especial manner, 
its power over the action of the longitudinal fibres of this viscus ; 
which, as I have already observed, (508,) have the greater agency in 
expelling the child. My reasons for thinking so are, first, because 
there were pains, even violent ones, from the commencement of the 
labour, until the Very period of exhibiting the ergot, without the child 
being forwarded by them in the slightest degree ; secondly bepause 
the rupturing of the membranes, a plan generally successful in in- 
creasing pain, failed ; thirdly, because the labour was terminated very 
soon after the character of the pains was changed, by the exhibition 
of the ergot — or, in other words, by the longitudinal fibres being 
stimulated to a healthy and effective action. 



Sect. II.— Of Rigidity, fyc. of the Soft Parts, as a Cause of Tedious 
and Preternatural Labour. 

958. Writers upon midwifery have but very imperfectly considered 
the rigidity of the soft parts as a cause of difficult or tedious la- 
bour — some, indeed, do not mention it, and others do so merely en 
passant, without proposing any specific treatment for its relief. It is 
so common a case, that every practitioner must have met with it; 
yet it has failed to make a proper impression, because time and severe 
suffering have eventually overcome it, though not always with safety 
to either mother or child. 

959. A rigid condition of the soft parts may, with much propriety, 
be considered the most frequent of the causes of a tedious labour ; 
especially as every woman may be subject to it, as well as every va- 
riety of presentation, be complicated with it. It may, perhaps, be 
difficult to define by words, the precise condition of parts, said to be 
rigid. But by this term we would wish to convey the idea, that cer- 
tain of the soft parts concerned in labour as the os uteri, perineeum, 
&c, offer an unusual resistance to the efforts which the fundus and 



RIGIDITY, &C. OF THE SOFT PARTS. 303 

the oody of the uterus make to expel their contents ; and it is in this 
sense only, we employ the term in this place. 

960. From this explanation, it seems to follow, that such a condi- 
tion of the mouth of the uterus and the external parts may exist, as 
will resist for a longer time than natural, (all other things being equal,) 
the expulsive efforts of the fundus and body of this organ ; so, w T e 
presume, that in these very cases, had no such resistance from the 
parts been present, that a less degree of force and a shorter continu- 
ance of contractions would have effected a delivery. 

961. The condition of the soft parts under consideration arises, 
perhaps, in a failure of reciprocity of sympathy in the several parts 
concerned in labour. For in fault of this good understanding, if we 
may so term it, the ordinary, and essential changes for an easy deli- 
very do not take place ; or, in other words, to employ the language 
of Mr. Hunter, the stimulus of relaxation is not given, or is not 
obeyed. This want of consent, however, does not necessarily imply 
a morbid condition of the parts concerned ; though it must, in many 
instances, have such an origin. Thus, there may be no morbid con- 
dition of the os uteri, though it resists for a longer time than usual 
the efforts of the fundus and body, when these parts have been prema- 
turely excited to action ; for in this case, all the terms of utero-gesta- 
tion have not been complied with. While, on the other hand, when 
the uterine development is perfect, and the soft parts resist the efforts 
of the body and fundus for an unnatural or unusual period, the pre- 
sumption is, that some morbid cause may be operating, so as to 
change the nature of the sympathies by which these parts are govern- 
ed, or that they have not come into play at such times. 

962. For, in the ordinary course of a healthy labour, the mouth of 
the uterus opens by some secret agency ; or at least without any ap- 
parent force ; and when this takes place, the efforts of the body and 
fundus are rendered as effective as prompt in terminating the labour ; 
but when this does not happen in the order just stated, the os uteri 
(all things being otherwise equal) is then said, in popular language, 
to be rigid. 

963. In labours of the latter kind, there is an unnatural resistance 
to be overcome ; and, to effect this, unfortunately, mechanical and 
other equally improper means are resorted to ; which, so far from ful- 
filling the intention in view, oftentimes increase the evil, and convert 
an o'herwise safe labour, (were it properly managed,) into one of 
great danger ; or, at least, into one of great tediousness and diffi- 
culty. In such cases, and with such consequences, it is at once 
evident, that a wrong principle governs the attendant ; for he attempts 
to overcome the resistance by increasing the force of the body and 
fundus, or by forcing open the resisting os uteri by mechanical means. 

964. The first he attempts, by the exhibition of stimuli of one 
kind or other, until the system is urged to the formation of fever ; or, 
to fulfil the other, he stretches the mouth of the uterus so rudely, or 
so repeatedly, as to produce in it an incipient, or, perhaps, a veryac- 



304 RIGIDITY &C. OF THE SOFT PARTS. 

tive inflammation. By such means, he defeats the operations of na- 
ture, which would have been most safely performed, if they had, by 
a well-regulated plan been permitted so to do. For, rest of body ; 
tranquillity of mind ; the abstraction of stimuli ; the loss of blood ; 
free bowels ; and not allowing the soft parts to be disturbed, by ill- 
timed and officious touching, or ill-conceived manual aid at the mouth 
of the uterus, have, in a thousand instances, overcome every diffi- 
culty presented by simple rigidity. 

965. Many of the errors committed in the treatment of the cases of 
tedious labour from rigidity, have arisen from the popular belief, that 
the dilatation of the os uteri is effected by the mechanical agency of 
the child, and the distended membranes ; and consequently, that this 
part is in a degree subject to the laws which govern impelled bodies. 
Two very important mistakes arise from this view of the subject; 
first, it prescribes a definite time for the dilatation of the os uteri ; for 
it seems to be assumed that the contractions of the body and fundus, 
must, in a given time, force open this part, by the repeated shocks it 
receives, from the foetus and distended membranes being urged so 
often against it. 

966. Hence we find Mr. Burns declaring "if the labour be going 
on all the time but slowly, it is a good general rule to effect the di- 
latation of the os uteri within ten or twelve hours at farthest from the 
commencement of regular labour."* This position is followed by 
necessary directions for the fulfilment of this intention by mechanical 
impulses and mechanical means; and though we acknowledge the 
mode pointed out for this purpose by that gentleman, still the condi- 
tions necessary to render them profitable, are as well guarded as the 
assumption of the principle will permit, still we must declare our un- 
feigned aversion to the practice ; for we are every way certain that 
it can be done with advantage in but very few instances, even by the 
skilful ; but never, without the risk of doing much mischief, by the 
unskilful or inexperienced practitioner. 

967. When the os uteri remains unyielding for a long time, it is 
an evidence that the natural processes, which so beautifully, kindly 
and safely effect this change, have from some cause or other been 
interrupted. And though mechanical force may be made to usurp 
the organic function, it nevertheless will always be at the expense of 
the health, or even the integrity, (be this more or less,) of that por- 
tion of the uterus to which force is applied. 

968. So well assured am I of this fact, that I never employ force 
to open the os uteri. Nor do I hold the argument, "that no mischief 
has been seen to follow this plan," of the slightest weight ; for we 
have it not in our power at the moment, to determine satisfactorily, 
any consequence, but the proximate, or immediate effect of the vio- 

* This rule as a general one may be correct, bat is often violated, or disappoints ; 
therefore it should be received with great caution, and acted on with great circum- 
spection. 



RIGIDITY, &C. OF THE SOFT PARTS. 305 

lence ; which may be, and most probably is, but slight, or even unap- 
preciable at the instant it is inflicted. But can we with any certainty 
declare, that many of the severe and dangerous chronic affections of 
the neck of the uterus, do not owe their origin to this cause ; for 
we have reason to conclude that carcinoma or cancer, or both, are 
sometimes the sequellae of this mechanical violence done during 
labour. 

969. There are but three situations of the os uteri with which we 
should ever interfere ; namely, first, when this part does not coincide 
with the direction of the uterine forces, and the axis of the vagina. 
In this case, labour may become very tedious, for the want of a cor- 
respondence of axis ; I therefore attempt to establish them, as directed 
in cases of obliquity of the uterus. See Section on the Obliquities 
of the Uterus, p. 117. 

970. But I never attempt even the slight change here spoken of, 
until the os uteri is yielding, and at the same time dilated, to the size 
of a dollar or more, and the pains in pretty full force. By this method 
not the slightest violence is committed; nor is even pain excited. 

971. Second. When the pains are powerfully protrusive, and the 
os uteri, though pretty amply dilated, yet not sufficiently so to permit 
the parietal protuberances to pass freely through it. In this case, 
much time and suffering are very often saved, by running the extre- 
mity of the finger round the margin of the os uteri, and gently 
stretching it. For, in many instances, if w T e gain an increase of half 
an inch in the diameter of this part, it is all that is required, to enable 
the head to pass it. 

972. Third. When the head is detained by the anterior portion of 
the uterus being in advance of it, and holding it, as it were, in a sling. 
In this case, that portion of the neck of the uterus, which is placed 
before the head, is obliged to sustain the whole force of the uterine 
efforts ; in consequence of which it becomes not only severely 
stretched, but it very effectually opposes the advancement of the pre- 
senting part, and gives rise to much unnecessary delay, as well as 
very much augmenting the sufferings of the patient. 

973. This case is one of very frequent occurrence ; and women 
who have ample pelvis, and especially those who have had several 
children. and are liable to the anterior obliquity of the uterus, are 
more particularly obnoxious to it. I do not know that any writer has 
noticed this cause of tedious labour; and though this cannot, strictly 
speaking, be considered as an instance of rigidity, it nevertheless has 
all the effects of that condition, as it creates delay, by a portion of one 
of the soft parts opposing the passage of the head ; and may, therefore, 
with much propriety, be considered under the present head of our 
subject. 

974. W T e are every way satisfied, from long observation, that this 
situation of the uterus, and of the head of the child, is one of the 
most common causes of delay when every thing else is favourably 
disposed, that occurs in practice; at least in this country. Whether 

27 



306 V RIGIDITY, &C. OF THE SOFT PARTS. 

this be so in Europe, where one of the remote causes, namely, a large 
pelvis, is not so general, we are unprepared to say ; but we are cer- 
tain, that the frequency of this relation of the head of the child, and 
the anterior portion of the uterus in this country, renders such labour 
more tedious by hours, than they would be, if no such interposition 
of the neck of the uterus took place. 

975. It is true, that the remora which the neck of the uterus offers 
to the passage of the head when down before it, never of itself 
creates a serious difficulty ; the evil chiefly consists in a painful and 
an unnecessary delay ; but as the case is always manageable, when 
it is proper to offer aid, it is certainly right to correct this deviation 
from a strictly healthy labour, as early as circumstances w 7 ill permit. 

978. The proper time to act. is, when the head occupies the infe- 
rior strait and vagina, completely ; when the pains are active; and 
when the os uteri is sufficiently dilated to permit the head to pass, if 
the axis of the head, and that of the os uteri, were coincident. 

977. To relieve the head from this state of embarrassment, we 
must draw the prolapsed edge of the os uteri by the point of the 
finger in the absence of pain, towards the symphysis pubis, and 
maintain it there, until a pain comes on. At this moment, the point 
of the finger is to be placed against the edge of the uterus, which 
is to be pushed upwards between the head of the child and the 
pubes. Should we be able to carry the prolapsed portion of the 
uterus above the advancing portion of the head, that is, so far as to 
permit the parietal protuberances to pass beneath or below the circle 
of the os uteri, the prolapsed portion of the neck of the uterus will 
suddenly withdraw itself from the finger and rise within the pelvis: 
the vertex will apply itself beneath the arch of the pubes, and the 
labour terminate almost immediately. 

978. It sometimes, however, requires several trials of this kind 
before they may succeed : but the attempt must not be abandoned 
because it fail a few times ; for the principle is a correct one, and 
should be acted upon perseveringly, should perseverance be neces- 
sary. We have every thing to gain, if we succeed; and nothing 
to lose if it fail : a disappointment, by the by, which cannot well 
happen, if the process for the restoration of the prolapsed part be 
properly conducted. 

979. We are convinced that we have seen very many labours 
shortened by hours, by acting as just proposed for such cases. It 
would be extremely difficult to determine, a priori, the duration of 
a labour of this kind, if left to itself; as the resistance which the 
margin of the uterus offers to the head, will for a long time, be 
more than equal to the power of the uterine forces ; consequently, 
the labour becomes stationary, and will continue to be so, until the 
margin of the uterus is obliged to yield by its losing a part of its 
power from attenuation, or perhaps by tearing. 

980. Nobody estimates the general rule, " to let a labour alone that 
is advancing well, and is natural in its general relations," more highly 



RIGIDITY, &C. OF THE SOFT PARTS. 307 

than we do — we look upon it as a most wholesome restraint when 
acted upon ; and as every way calculated to diminish ignorant and 
mischievous officiousness. But this rule, like every other general 
rule, has its exceptions ; and we may be even accused of violating it 
unnecessarily, when we make the cases under consideration excep- 
tions ; but we should feel but little concern upon this head, if the 
charge be even preferred against us; as we are certain that we are 
justified in making them, from an ample experience. 

951. Many, nay, perhaps every body, (for we have said that we did 
not know that this case had been noticed,) will condemn what we 
have said upon this subject, and consider our directions as unneces- 
sary, if not mischievous, because they have never had recourse to 
them, but have permitted the uterus to perform this duty unaided ; 
therefore, they say nature is competent to the work, and when she is 
competent, she is not to be interfered with. Were this rule rigidly 
acted up to, there would be an end to improvement, not only in the 
obstetric art, but in the whole range of practical medicine. Our ex-, 
perience, however, teaches us not to heed this sweeping, indiscrimi- 
nate rule ; for it is not sound practice to permit nature to struggle 
through difficulties, merely because it is supposed she can struggle 
through them ; and to leave it for some time a moot point, whether 
or not the case will eventuate in safety, when aid, as certain, as safe, 
is always at command. Nor does this application of the finger ever 
produce pain or other inconvenience, if properly and gently managed. 

952. Besides, much delay is sometimes experienced from this 
dropping down of the anterior portion of the uterus, by interrupting 
the pivot-like motion of the head, (627,) from completing itself; espe- 
cially when the head occupies pretty strictly the inferior strait. In 
this case the posterior fontanelie will remain for a long time stationary 
behind one of the foramina ovalia ; for its advancement towards the 
arch of the pubes is prevented by the prolapsed portion of the uterus 
interfering with the motion just mentioned, by embracing too strictly 
the advancing part of the head. 

983. But the pivot-like motion of the head is almost always re- 
stored the instant we succeed in passing the dependent portion of the 
uterus above the head of the child by the point of the finger, as di- 
rected above. 

984. The several situations of the os uteri just described, are the 
only ones I ever interfere with; for it should be thick and rigid, 
though pretty well opened, I never have recourse to mechanical 
means for its farther enlargement ; I depend upon more time, or upon 
the therapeutical means to be named presently. 

985. But let us now consider the rigidity of the os uteri as a cause 
of tedious labour; we will treat of its several varieties, its conse- 
quences and mode of treatment. 



308 



SPECIES OF RIGIDITY. 



Of the Species of Rigidity of the Os Uteri. 

986. First, it may arise in the mouth or neek of the uterus, from the 
circular fibres of these parts maintaining their power inordinately long ; 
but not inflamed. 

987. Secondly, this condition may be attended with inflamma- 
tion. 

988. Thirdly, it may arise from previous injury done the parts, 
either by mechanical violence, or inflammation, and its consequences. 

989. Fourthly, it may happen from a relative cause ; as the dispro- 
portionate powers between the longitudinal and circular fibres. 

990. Fifthly, it may proceed from the too powerful exercise of the 
tonic contraction of the uterus, especially of the fundus and body. 



Rigidity of the First Kind. 

991. This species maybe divided into three varieties; viz. 1st, 
when the subject is very young ; 2dly, where she is advanced beyond 
the twenty -fifth year; and, 3dly, where the uterus is prematurely ex- 
cited into action. 



Var. 1. 

992. In this variety the soft parts are found to yield very often with 
great reluctance ; and thus making this labour extremely tedious and 
painful ; it would seem to arise from the incomplete development of 
the uterus — but each of the species and varieties will be best ex- 
plained by appropriate cases. 



Case First. 

" Miss V., aged fourteen years and a-half, was taken in labour 
January 14, 1790. She had been in pain thirty-six hours, before I 
saw her; that is, she complained for that period, though the pains 
were not very severe ; about twelve hours before I visited her, the 
waters were discharged ; the mouth of the uterus was but very little 
opened, and the external parts not favourably disposed. They now 
became very severe, and the head was pressed pretty deep into the 
pelvis : she was extremely costive, and had passed no urine for many 
hours : an injection was ordered, which operated very freely ; the 
catheter was introduced, and nearly a quart of water was drawn off' — 
she was much relieved by these discharges. An hour was given, in 
hope that a favourable change might take place in her labour. There 
was but very little heat in the vagina, for she had been rarely touched. 



SPECIES OF RIGIDITY* 309 

She had, however, by the advice of her midwife, been placed over hot 
water, and fumigated with burning onion-shells, but to no purpose. 

I now bled her fifteen ounces; this produced some little change in 
the mouth of the uterus, but not sufficient to permit the head to pass, 
as it contracted and stiffened with each pain. In an hour more she 
was again bled fifteen ounces ; this produced sickness of stomach, 
which was my signal for stoppings. Upon examination now, the parts 
were found sufficiently dilated ; there was a temporary suspension of 
the pains ; but they soon returned, and were of competent force, and 
much more tolerable — the labour was soon after terminated. 



Var. 3. — Or where tJie Subject is not young, but ivith her first 

CUM. 

993. The same general phenomena present themselves in this va- 
riety as in the first, but this case is generally rather more obstinate. 



Case Second. 

1798, February 17tb, Mrs , aged forty, in labour with her first 

child; she had been long in labour previously to my seeing her, and 
had suffered much — her pains were in quick succession; the 'waters 
were still undischarged : the uterus opened to about the size of a 
quarter dollar, its edges very firm ; no disposition in the external parts 
to relax — she was bled largely, (40 ounces,) and was delivered in half 
an hour after. 



Var. 3. — Or wliere the Uterus is prematurely called into- Action. 

994. This may happen at any period of gestation, or iaany subject ; 

but I am only now considering those cases where this takes place at 

the last period. It would in this variety be highly useful to distinguish 

it from the two just mentioned; as in the beginning it requires very 

different treatment. The following marks may serve to detect it: 1st. 

The unexpected portion of the neck of the uterus may sometimes be 

perceived by the touch, as at the eighth month or a little after ; 2dly, 

the os uteri is rigid, during, and in the absence of pain ; 3dly, the pains 

are more irregular in their accession* and in their continuance ; 4thly, 

retion of mucus, nor disposition in the perinseum to relax ; 5thly, 

folding of the abdominal tumour; and the knowledge of some 

excitement, or muscular exertion having preceded the 

of pain. 

- ,ould these pains, however, be suffered to proceed without 
interruption, it will eventuate in a painful and tedious labour — it, 
therefore, should be our first care to appease uterine contraction, by 

27* 



310 SPECIES OF RIGIDITY. 

remedies suited to the condition of the patient — blood-letting should 
be premised, if the pulse merely permit it, and without declaring its 
absolute necessity ; especially as the case may require repeated and 
large doses, sometimes, of laudanum. But above all no injudicious 
attempt should be made to hasten the labour. Rest should be strictly 
enjoined ; the bowels should be opened by mild laxatives, if costive : 
this should be followed by injections of laudanum and water, pro re 
nata—the diet should be mild, and in small quantities. By this kind 
of treatment we may very often have it in our power to interrupt this 
disagreeable anticipation of labour, as the following case, among 
many others, shows. 



Case third. 

1790, January 29th, Mrs. M. L. , aged twenty, pregnant of 

iier first child, after standing all day at the ironing-table, was seized 
with pretty regular pains. There was no subsiding of the abdominal 
tumour ; no secretion of mucus ; the os tineas not entirely obliterated. 
There was very little tension of the membranes during a pain : from 
these circumstances I was disposed to believe the uterus had been 
prematurely excited to action. She was ordered to lose twelve ounces 
of blood ; to keep quiet, and receive an enema of a gill of water, and 
a tea-spoonful of laudanum — pain soon subsided ; she went a fortnight 
longer, and her labour proceeded kindly, and was not of long du- 
ration. 

996. In cases similar to the above, much mismanagement frequently 
takes place ; especially when the patient is under the care of an ignorant 
widwife, who supposes the attending pains can only proceed from a 
commenced labour ; particularly if the reckoning of the patient be 
nearly expired : she is of course frequently and oftentimes rudely 
handled ; the uterus irritated, and the whole system stimulated by im- 
proper drinks or remedies, with a view to hasten the labour, as it is 
called — •the following case is in point.. 



Case Fourth. 

1790, August 11th. Mrs. C. pregnant with her third child, aged 
'zwenty-eight, after a severe fright, was attacked with pains ; as her 
midwife was engaged at the time she was sent for, I was called on. 
From her being disappointed in her midwife, she became very much 
alarmed, and the pains ceased for six hours. At the expiration of 
this period they returned, and the midwife arrived soon after ; she 
examined her, and found nothing like labour. She gave her a large 
dose of laudanum, which, not easing her, was repeated in two hours 
more. Her pains became more violent ; she had much fever, at- 
tended with delirium. 



CICATRICES. &C. FROM LOCAL INJURIES. 311 

I was now sent for a second time : upon examining the patient, 
the uterus appeared evidently to have been forced into contractions 
by the fright, and these perpetuated by the improper conduct of the 
midwife ; but things were now in such a situation that it would have 
been in vain to have attempted stopping the progress of the labour. 

The mouth of the uterus was thick and hard, and opened to about 
the size of half a dollar. As there was so much fever, I thought 
proper to bleed and purge her ; these had a good effect, as her fever 
and delirium were diminished, but the mouth of the uterus was firm, 
and not augmented in size since she was examined before, (six 
hours ;) she was again bled pretty largely, the delirium went off en- 
tirely, the uterus opened, and she was delivered in less than an 
hour. 

997. Had not this patient been bled very liberally, there is every 
reason to believe her labour would have had a serious termination — 
she lost in the two bleedings about fifty ounces of blood. This case 
serves as a contrast to the one just before related ; as I believe the 
bleeding which preceded the anodyne enema, enabled the latter to 
produce its beneficial effects ; and I am also of opinion, that had a 
bleeding been premised in this ease, the patient would have suffered 
much less, and gone some time longer. 

998. I think it an important rule in the farther arrangement of these 
labours, when pain cannot be suspended by the means pointed out 
above, to abstract stimuli of every kind, as much as possible ; to 
have the bowels well opened ; and then to allow the circular fibres 
of the mouth of the uterus to be a little fatigued, before we employ a 
larger or sufficient bleeding to effect the farther dilatation. We may 
easily know when they begin to be fatigued, by their readily yielding 
when the finger attempts to stretch it in the absence of pain. Bleed- 
ing alone sometimes quiets this premature motion of the uterus. 



Sect. III. — Cicatrices or other Imperfections arising from Local Inju- 
ries. 

999. It was not until the year 1796 that I learnt the value and cer- 
tainty of blood-letting in cases of local injury from inflammation, or 
from a solution of continuity in the soft parts concerned in labour, 
where in healing they became contracted, and otherwise severely in- 
jured, though I had so frequently experienced its value in cases where 
they had obstinately refused to yield to the common agents of deli- 
ver}-, when in the natural condition. The long continued pressure of 
the child's head during its passage ; the ill-judged use, and the worse 
directed application of instruments ; and the reprehensible neglect of 
the perinaeum when much distended — have given rise to more or less 
grevious injuries of these parts. These accidents will retard delivery 
in proportion to their extent, and if some oppose but a trifling resis- 
tance to ihe passage of the child, there are others, from their seve- 



312 CICATRICES, &C. FROM LOCAL INJURIES. 

rity and extent, which may render it impossible without adventitious 
aid. 

1000. Cutting instruments have been not only considered as- justi- 
fibly employed in such cases, but deemed absolutely essential for the 
termination of the labour, (Baudelocque, &c.) in many instances, where 
bridles, indurations, and cicatrices have deranged the natural order 
of the parts, or so disturbed their natural functions as to render them 
no longer subservient to their proper uses — hence the necessity of 
means so severe as the scalpal or bistoury for the relief of the mother 
and child. 

1001. I trust, however, this terrible alternative is no. longer, or, at 
least, not so frequently necessary as heretofore ; since it is found, in 
some of the most distressing and extensive injuries of this kind, to 
yield in a very short time to the relaxing influence of a copious bleed- 
ing. To show the certainty of this remedy, even under the most un- 
promising circumstances, I will relate several cases where it was em- 
ployed with the happiest effects*. 



Case First. 

1796, June, I was called to Mrs. T , in labour with her se- 
cond child. When I arrived, I received the following account of the 

case from the midwife : " Mrs. T has been in labour sixteen 

hours ; the waters discharged six ; the mouth of the womb is but 
little opened ; and, when in pain, the os externum seems to close up ; 
the child is as high as ever, though many things have beea given to 
force the labour. She has passed no water for twelve hours, and is 
very costive." (Baudelocque, &c.) 

I found her very feverish, complaining of great heat in her abdo- 
men, and violent pain in her head. On examining per vaginam, I 
found, as the midwife had stated, that the os tincse was but little 
dilated ; its edges very rigid and hot — as was the whole tract of the 
vaginas ; the rectum much distended with feces, and the bladder by 
urine. The head of the child was still above the brim of the supe- 
rior strait ; but its situation could not be exactly determined, as the 
os uteri was not sufficiently opened for the purpose. 

She was bled immediately to the amount of twelve or fourteen 
ounces, and an injection was thrown up, which procured tw T o stools 
and a discharge of urine. Upon examination, I found the mouth of 
the uterus more dilated ; and I was enabled to determine that the 
presentation was a perfectly natural one, and the head lower in the 
pelvis. The pains were very powerful ; the head at length cleared 
the upper strait, and the vertex was about to turn under the arch of 
the pubes, but completely enveloped in the uterus — during a pain, 
the perinseum was much distended ; the os externum, instead of 
yielding to the impulsive force of the uterus, rather closed, so that 
two fingers could not be retained at once. A seam, pr cicatrice, 



CICATRICES, &C. FROM LOCAL INJURIES. 313 

formed a kind of barrier in the vagina ; and the head, in consequence, 
was thrown to the right side of the inferior strait, where the parts 
were so extremely stretched, that I feared, at each pain, the head 
would burst through them, in spite of every exertion to the con- 
trary.* 

From the oblique situation of the head, with respect to the vagina, 
the os externum, instead of answering to the axis of the inferior strait, 
was mounted up directly to the pubes ; consequently, the right side of 
the vagina, perinagum, and rectum, had to support the greater part of 
the force exerted by the uterus and its auxiliary powers. In order to 
counteract their influence, I supported the external parts with my 
hands, and made, during each pain, a strong pressure against the head, 
directing the woman, at the same time, to suspend her voluntary 
powers as much as possible. 

Six hours were spent in this manner without advantage ; the os 
uteri still rigid, hot, and but partially dilated ; the os externum not 
disposed to yield, and the cicatrix as firm as ever. The head ad- 
vanced, notwithstanding my efforts to prevent it ; so that the vertex 
covered with the uterus had partly emerged from under the arch of 
the pubes. At this period it was extremely difficult to touch the 
mouth of the uterus, as it had receded towards the sacrum in propor- 
tion as the vertex had descended. 

The soft parts were very hot and dry ; and I began to entertain 
serious apprehensions for the patient. I was ten miles from the city, 
and no one was near on whose judgment I could rely. In this 
dilemma I had nearly resolved to divide the parts; believing it pre- 
ferable to permitting the head to force its way through them, which 
I began to consider as inevitable ; when fortunately Dr. Pbysick's 
case of luxated humerus occurred to me. This determined me to 
try the effects of bleeding, ad deliquium animi. I represented to the 
friends of the patient the danger of her case ; the possible result of 
the bleeding ; and the inevitable one, did it not succeed. They 
agreed to the trial. I had the patient placed on her feet, while the 
midwife firmly supported the perinseum, &c. A vein was opened ; 
and allowed to bleed, until she fainted. f She was now placed on 
her side in the bed. 

On examining her, every thing appeared better; the external parts 
were perfectly soft and yielding ; and the os uteri pretty fully dilated ; 
but no pains succeeded, during the time I thought proper to wait; 

* The cicatrix, just spoken of, was formed by the healing up of an extensive lacera- 
tion which the pjtient suffered in her former labour. It ran from the inferior termi- 
nation of the left labium, to about the termination of the sacrum. I judged of the ex- 
tent of the injury by the cicatrix, and this could be traced to this point. Conversing 
upon this case, some time after, with the practitioner who had delivered her before, 
he confirmed my supposition. It was a long time before the wound healed ; and the 
woman suffered much from the excessive ?md long continued discharge; but from this 
she recovered: and was, when I was called to her, apparently in robust health. She 
was about twenty. two years of age, of short stature, and rigid fibre. 

f The quantity of blood drawn was upwards of two quarts. 



314 CICATRICES, &C. FROM LOCAL INJURIES. 

(which was half an hour, the patient continuing very faint all this 
time,) the parts being now in a proper situation for delivery, I in- 
troduced the forceps, and delivered a living and healthy child. The 
parts yielded very readily without laceration ; and the woman had a 
rapid recovery. 

1002. As cases of the kind I am now considering are highly in- 
teresting, both from the extent of injury done to the parts, and their 
rarity, I trust I shall be excused for detailing another ; especially as 
the mode of treating them is as certain, as it is novel.* 



Case Second. 

On the 12th September, 1798, I was requested to visit the wife of 
Samuel G., in consultation with Dr. Jones. I was informed by the 
doctor, that Mrs. G. had been in labour sixteen hours; the waters 
evacuated themselves early ; her pains were frequent and strong ; but 
there was not the least disposition in the soft parts to dilate. f 

I examined the patient, and found the os externum scarcely large 
enough to admit the finger, and mounted against the symphysis pubis, 
in consequence of the perinaeurn being very much distended by the 
head of the child. The os uteri was rigid, and but little opened ; a 
kind of bridle, or small column of flesh ran from the inferior edge of 
the symphysis pubis, and lost itself in the perinaeurn below ; against 

* Dr. Davies gives the credit of large bleedings in parturition to the late Dr. Rush. 
I feel that I am entitled to whatever praise or blame may attach to this practice. 
This has been long since ceded to me by that gentleman, with all the frankness and 
liberality which so constantly characterized him. But Dr. Davies does not appear to 
understand the circumstances under which this practice is recommended. I infer 
this from his observations on the use of blood-leiting, where rigidity is a cause of 
difficulty. 

" For my own part," says he, " I can see no good reason for bleeding prospec- 
tively, or in anticipation of a mere possibility, which might or might not be realized 
by the event. To say the least of such a practice, it would appear to be a most un- 
necessary encroachment upon the ordinary dispositions of nature in the affairs of a 
function which she usually performs very safely and satisfactorily without any such 
interference." — Elem. of Oper. Mid. p. 89. 

This passage would lead to the conclusion that I recommend (for it is not Dr. Rush,) 
this operation previously to any appearance of the necessity; which is far from being the 
case. This opinion is strengthened by what immediately follows : " Bleeding, on the 
other hand, as a remedy or a corrective of an actually existing rigidity of the soft 
parts, whether or not accompanied by more than ordinary constitutional excitement, 
is a power of great and unquestionable value," p. 90. Now, this is conceding all that 
I have ever contended for in the use of this remedy. 

t This patient, like the one whose case has just been related, had also suffered a 
laceration of great extent ; the parts after a considerable lapse of time, healed ; but so 
unfortunately, as almost entirely to obliterate the vagina. I was called upon for advice ; 
the woman's situation was truly distressing ; the passage, or vagina, was so much con- 
tracted, as not to exceed in size a common writing quill ; the parts extremely callous; 
and a continual and profuse discharge of acrid, fetid pus, kept her in a constant state 
of misery and ill-health. My friend, Dr. Physick, was also consulted at the same time: 
by a persevering use of sponge tents, &c, the parts became sufficiently dilated to admit 
imperfectly the venereal congress ; soon after, she became pregnant ; and the conse- 
quences of this pregnancy furnish the above case. 



CICATRICES 



&C. FROM LOCAL INJURIES. 315 



this the head was firmly pressed. The head was situated naturally ; 
and so far advanced, that the vertex was about to emerge from under 
the arch of the pubes, covered with the uterus ; and had been in this 
situation six hours previous to my visit. All that had been done 
during this period, was the occasional exhibition of laudanum, with a 
steady pressure against the perinasum, to prevent the head escaping 
through it. In this situation of things what was to be done ? 

My ingenious and much lamented friend, Dr. Elihu Smith, of 
New York, upon the receipt of the history ef the case just related, 
suggested the trial of an infusion of tobacco in similar cases, as a 
substitute for such extensive bleeding ; affirming the effects were very 
like those produced by copious blood-letting ; such as nausea, vomit- 
ing, syncope, and relaxation. I was pleased with the idea, and de- 
termined to employ it the first opportunity — the case under conside- 
ration I believed to be as favourable a one as could well occur ; I ac- 
cordingly proposed the tobacco infusion to Dr. Jones, who cheerfully 
consented to its trial. 

A strong infusion of tobacco, after several ineffectual attempts, was 
thrown up the rectum ; it produced great sickness, vomiting and 
fainting ; but the desired relaxation did not take place — we waited 
some time longer, with no better success. In the course of an hour, 
or an hour and a half, the more distressing effects of the infusion w x ore 
off; but, resolved to give the remedy every chance in our power, we 
prevailed on the patient, with some difficulty to consent to another 
trial of it : its effects were the same as before — great distress, without 
the smallest benefit ; the parts remaining as rigid as before its exhi- 
bition.* 

Supposing the bridle just spoken of, might have some influence on 
the development of the parts, I divided it, but without any evident 
good. We now proposed the remedy that had so completely suc- 
ceeded in the former case — namely, bleeding nearly to fainting ; to 
this the patient consented. We placed the patient on her feet, taking 
care to have the perinceum guarded, during the operation. Upon 
taking away about ten ounces of blood, she became very faint ;f she 
was immediately laid upon the bed; and the most complete relaxation 
had taken place ; the forceps were applied, and our patient was deli- 
vered in a few minutes of a fine healthy girl. The mother was com- 
fortably put to bed ; and every thing went on in the ordinary way until 
the sixth day at which time she was seized with a violent cholera 
morbus, and convulsions, (to which complaints she was subject,) and 
died in twelve hours. 

* Dr. Blundell recommends an infusion of tobacco, where it is necessary t>> turn, 
and whore the uterus contracts very strongly. We should not, however, join in this 
recommendation, from what we observed in the case now relating. As a dernier 
resource, it might be tried : but this must be at the discretion of the practitioner, and 
not from any recommendation of authorities. 

t The subject of this case was a delicate woman, and wont to become very faint 
upon the loss of a little blood. 



316 RELATIVE RIGIDITY. 

This case, notwithstanding its unfortunate termination, fully estab- 
lishes the influence of blood-letting in this very distressing kind of 
rigidity, and proves its action to be different from that of tobacco ; 
though the latter produces sickness, vomiting, and syncope. I do 
not think the slightest blame can attach to the bleeding, as the woman 
was very well until the sixth day ; when diseases to which she was 
subject, supervened, and carried her off. 



Case Third. 

On the 26th September, 1800, I was called, in consultation with 
Dr. Ruan, to a woman in labour. She had been twelve or fourteen 
hours in travail with her second child.* The pains were frequent and 
strong ; the waters had been discharged some time ; the head was 
favourably situated, and completely occupied the vagina; the perinasal 
tumour large ; the os externum, which did not exceed in size a finger 
ring, admitted the finger with some difficulty, in the absence of pain ; 
during a pain it would be thrown up against the inferior edge of the 
symphysis pubis, so as not to admit the finger, or permit it to remain, 
if it had been previously introduced. Externally, a large cicatrix was 
found to run to the very verge of the anus; internally, it could be 
traced farther. This seam prevented the unfolding of the external 
parts so effectually, that the repeated efforts of the uterus for several 
hours was sufficient to make them yield, though the head had been 
closely applied to them for that period. 

The patient was a strong healthy woman — considerable fever — the 
pulse strong, frequent and hard. I proposed bleeding ad deliquium, 
to which Dr. Ruan consented. A vein was opened immediately, and 
we took away about fourteen ounces of blood ; but as the pains were 
very rapid, we were obliged to draw it while she was in a recumbent 
posture ; no disposition to syncope was manifested. This quantity, 
however, had some effect, as there was evidently a disposition in the 
parts to relax, and an abatement of the severity and frequency of the 
pains. A second bleeding was determined upon, and to perforin it 
while the patient was in an erect position. We effected this with 
some difficulty, but upon taking five and twenty or thirty ounces of 
blood more, she fainted — she was laid on the bed, and in a few 
minutes was delivered by the forceps, of a fine healthy boy — the 
patient recovered rapidly without accident. About three years after, 
I again delivered the same person by the same means. 

* With the first she had suffered an extensive laceration of the perinaeum. 



RELATIVE RIGIDITY. 317 



Relative Rigidity. 



1003. I have maintained, that not only the different parts of the 
uterus into which it is usually divided, may act separately and inde- 
pendently of each other, but that even the different sets of fibres of 
which it is composed may do the same ; hence that peculiar rigidity 
I have denominated " relative ;'.' by this we are to understand that the 
circular fibres act with a force superior to the longitudinal. This may 
happen from the latter losing a portion of their strength, which will 
necessarily give to the circular a relative superiority of force ; or, it 
may happen that the circular fibres, from some cause or other, may 
have an increase of power, which will, of course, make the longitudinal 
relatively weaker. Whichever way it may take place, the result is 
the same, for the labour will become stationary. 

1004. This case may be known by labour coming on kindly at first, 
but after a certain period, gradually diminishing in force, by the mouth 
of the uterus having a disposition to dilate ; by its thickening; by the 
presenting part not protruding during a pain ; b) pain extending itself 
over the whole abdomen ; by a sense of suffocation ; by a hard, full, 
depressed pulse ; by the irregularity of the pains, both in force and 
frequency : the mouth of the uterus, in this case, cannot open agree- 
ably to the order of nature, as the fibres destined to keep it shut, are 
relatively stronger than those intended to open it. 

1005. In consequence of this transfer, or peculiar disposition of the 
power, the longitudinal fibres contract more feebly and transitorily ; 
the mouth of the uterus does not dilate, though not preternaturally 
rigid ; the abdominal tumour does not continue to subside ; there is a 
secretion of mucus, and a disposition in the external parts to relax ; 
but the os uteri cannot dilate until the longitudinal fibres have shaken 
off their torpor, or, in other words, not until the cause of this torpor 
is removed : when this is done, they resume their healthy contractions, 
and the labour, for the most part, is quickly terminated. 



Case. 

Mrs. W -, June 10th, 1805, was taken in labour with her tenth 

child : her pains began smartly, but soon ceased almost entirely — she 
continued in this situation from ten o'clock in the evening until six 
the next morning ; at this time I was called. I found her with nearly 
all the symptoms above enumerated ; she was bled twenty ounces ; 
pains came on immediately, and she was quickly delivered. 
28 



318 TONIC RIGIDITY. 



Sect. IV. — Tonic Rigidity ; or Rigidity from the Premature Escape 

of the Waters. 

1006. This only takes place after the waters have been a long time 
discharged — the tonic contraction of the uterus then becomes powerful, 
and its force will be in proportion to the healthy disposition of this 
organ, and the time which may have elapsed since the waters were 
drained off. I have already remarked upon this disposition of the 
uterus when freed from its contents, and stated its high and important 
uses, to the- woman at the time, (251 ;) I have also referred to the in- 
conveniences to which it sometimes gives rise, when speaking of the 
causes of preternatural labours, and given a case illustrative of it, 
(678.) Cases of this kind have frequently occurred to me ; but in some 
I have been obliged to turn after bleeding, (which was impossible be- 
fore,) and in one or two others I have been obliged to use the 
forceps. 

1007. There is a kind of rigidity, or, more properly speaking, a 
cartilaginous or scirrhous condition of the neck or mouth of the uterus, 
which is so confirmed and indurated, as not to yield to the powers of 
the body and fundus, nor to blood-letting, however far it may be 
carried. These cases, fortunately, are very rare ; so rare, indeed, 
that I have never met with an instance, of the kind. They are, how- 
ever, recognised by Baudelocque and other writers. 

1008. Baudelocque says of them, u Sometimes the pad which con- 
stitutes the neck of the uterus, in the latter periods of pregnancy, and 
in time of labour, is hard, scirrhous, incapable of any extension or 
dilatation, so as entirely to hinder the exit of the child. After a con- 
venient delay to ascertain that the efforts of nature cannot overcome 
the resistance, and the administration of proper methods to relax it, 
it must be cut in several places, as some practitioners have done. 
These incisions are preferable to rents which might take place in it, 
and have never been attended with the same consequences. They 
must be made more or less extensive, according to the pad, which is 
callous : but always so much so, that the orifice may afterwards open 
sufficiently." Vol. III. p. 205. 

1009. The success of this plan has been verified, in this country, 
as the case of Dr. Thomas Archer most satisfactorily proves. Dr. A. 
was called to a woman in the thirtieth year of her age, and in labour 
with her first child. The os uteri was found to be very little opened, 
" and forming a thick cartilaginous ring, which neither yielded to nor 
was softened by the pains." After ordering a bleeding to some extent, 
to be purge/1, &c., he took his leave, and left her to the midwife who 
had charge of her. He did not see this patient again until late in the 
following day. Soon after his arrival, the uterus, loaded with its con- 
tents, was pushed through the os externum. The child was dead, he 
thought, beyond doubt, and had, most probably, been so for ten days. 
As the case appeared to him hopeless, and as it was not in his power 



OVER-DISTENTION OF THE UTERUS. 319 

to procure a consultation, he resolved on making incisions in the 
mouth of the uterus ; he accordingly, by means of a common lancet, 
made three cuts in the uterine circle ; one anterior, one posterior, and 
one laterally. The incisions were each about two inches long. The 
pains, though not strong at this time, were sufficient, however, to expel 
the child almost instantaneously. The woman was put to bed, and 
no unpleasant symptom followed. Med. and Phys. Jour. Vol. 1. p. 
157. 

1010. In addition to this case, and as confirmatory of its success, 
we may mention those of Moscati. A woman whose os uteri had 
suffered from a previous labour, was found at the time of her second, 
to be so restricted and dense as to require an operation. This was 
performed by making several incisions in the circle of the os uteri, 
which dilated after a time sufficiently, and without farther injury to 
permit the child to pass — this operation was repeated upon another 
occasion on the same woman with similar success. This method 
Moscati thinks better than that recommended by Smellie, and appears 
to consider it original. (See Bulletin Universal, &c. No. 6. July, 
1S27.) But the above case will show that Dr. Archer had performed 
this very operation long before, and with equal advantage. 



Sect. V. and VI. — Over- distention of the Uterus, and the Membranes 
too Dense, as a Cause of Tedious Labour. 

1011. In many cases of this kind, a well directed interference may 
very much abridge the duration of suffering ; but when and how to 
interfere, with success, can only be known by those who possess 
correct principles, and have had long experience. Thus, Mr. Burns 
tells us, and to the success and truth of which we can bear ample 
testimony, " that in many cases a very moderate resistance retards 
the expulsive process, and renders the pains irregular or inefficient. 
And I know by experience that the membranes may be so tough as 
not readily to give way, and in this case the pains become less effec- 
tive, and the labour is protracted till they be opened. Whenever the 
resistance is removed the pains become brisk and forcing." 

1012. Of cases of this kind, we have seen many ; but one of the 

most remarkable happened in September, 1826. Mrs. , at the 

full period of her pregnancy, as she calculated, was attacked on the 
eighteenth of August, with severe alternate pains, which caused me 
to be sent for. These pains were excessively severe ; but without 
either force or regularity. There was no secretion of mucus, nor was 
the os uteri dilated, though soft, and the whole of the inferior portion 
of the uterus was excessively distended and very thin. Dr. Campbell 
says, (Intr. to the Study of Mid. p. 215,) " Although over-distention 
of the uterus is a cause which most systematic writers have allowed, 
yet we have no distinct evidence of the existence of such a state ;*it 
is, I suspect, purely presumptive." We can assure Dr. C. that this 



320 OVER-DISTENTION OF THE UTERUS. 

is not so, notwithstanding his attempt to reason us out of the belief. 
His statement, on this point, as regards the economy of the gravid 
uterus, which he appears to think sufficient to disprove this condition 
of the uterus, is based upon a presumption, according to his own 
words. For we can see very little against the occurrence of such a 
state of the uterus. For, if we admit his postulate, that the system 
furnishes materials in proportion to the necessity for the increase of 
expansion, he must admit that this just proportion is only exactly so, 
when the enlargement of the uterine cavity is in a normal condition. 
Has not Dr. C. known dropsy to take place within the cavity of the 
uterus, and has not the uterus yielded to the influent serous deposi- 
tion ; and this, to a great extent, without provoking uterine contrac- 
tion to force it off? Dr. C. takes it for granted that the os uteri be- 
comes considerably dilated in the early stage of labour, and advances 
the contents of the uterus considerably in the pelvic cavity ; a circum- 
stance, we have said above, that does not take place, even after long- 
continued, reiterated, and very painful contractions: consequently the 
uterus is not relieved by forcing the membranes with their water low 
in the pelvis, and thus causing the uterine fibres to act with the "ne- 
cessary force." The case just now relating, will, we think, satisfy 
any unprejudiced mind, that the suffering and cause of delay were 
owing to a superabundance of liquor amnii. After waiting several 
hours, not the least alteration was observed, though the pains had 
continued with much severity. I ordered a gill of water and a drachm 
of laudanum to be given as an enema. This application completely 
tranquillized the pains for many hours ; they, however, returned with 
as much violence the day following ; and were again relieved by the 
same remedy ; nor did they return until the 21st of September, nearly 
five weeks from the first attack. 

1013. This second attack was every way similar to the first, with 
the addition of an acute pain in the right side, which was augmented 
by coughing, or a full inspiration. Twelve ounces of blood w r ere 
drawn ; the bowels freely opened by Epsom salts and calcined mag- 
nesia ; and the diet and drink restricted to barley-water. The con- 
dition of the uterus was very much the same as it was when exa- 
mined on the 18th of August. The bleeding and purging afforded 
much relief, by removing the pain from the side ; but there w T as no 
abatement of the uterine action, or pain ; for such it certainly was, as 
the whole uterine globe was found firmly contracted or hardened at 
each pain. The laudanum enema was repeated with the previous 
good effect, and my patient remained quiet until the day but one fol- 
lowing, namely, the 23d, when there was again a renewal of the 
previous symptoms, which were again removed by bleeding, purging 
and laudanum. On the 24th, the same sufferings were endured ; and 
relieved as before. On the 25th, my patient was again seized at the 
hour with the same symptoms, together with great feebleness, and 
almost constant disposition to syncope. The pains were occasionally 



0VER-D1STENTI0N OF THE UTERUS. 321 

severe, but far apart ; not at all protrusive; and each was followed 
by nearly complete syncope. 

1014. The situation of ray patient seemed now to call for some 
efficient relief, or she must succomb. As the uterus was very thin 
and much stretched, and the os uteri was pliant, though not dilated 
beyond three-quarters of an inch, I thought it would be best to rup- 
ture the membranes, and give an opportunity to the uterus to contract, 
and, as I believed, remove the disposition to syncope : this was ac- 
cordingly done ; and it gave issue to an immense quantity of liquor 
amnii. My patient received immediate benefit from this operation ; 
the sensation of distention was relieved, and the faintness was instantly 
removed. In about half an hour, the pains became efficient, and the 
os uteri began to dilate ; and in about an hour and a half, my patient 
was safely delivered of a large male child. No after-inconvenience 
was experienced. 

1015. This case is remarkable for the numerous unsuccessful efforts 
the uterus made to disembarrass itself, and the severe sufferings the pa- 
tient underwent during these efforts ; and may with as much certainty 
as almost any with which I am acquainted be looked upon as a pro- 
tracted case of gestation.* The patient considered her term as having 
fully expired on the 18th of August ; the period at which pains first 
manifested themselves ; and as far as the usual mode of reckoning, 
and the complete development of the uterus at that time can be re- 
lied on, incline us to the belief that she was correct ; and that she 
really had arrived at ten months and a week, complete, when deliver)' 
took place. 

1016. I can anticipate nothing, even at this moment, but a disas- 
trous issue, had I neglected to rupture the membranes ; as several 
very distressing as well as alarming symptoms, had begun to show 
themselves; such as a cold, clammy skin ; a small,. frequent pulse; 
laborious breathing, and great proneness to syncope ; all of which 
were instantly removed by taking off the distention of the uterus, by 
giving an opportunity for the liquor amnii to escape by rupturing the 
membranes. This case must not be confounded with the Hydroam- 
nios or a dropsy of the ovum, one of the few diseases to which it is 
liable. It is almost always caused, as far as my experience goes, by 
a latent venereal taint on the side most frequently of the father, and 
this, for reasons that will immediately present themselves. In these 
cases the woman rarely goes to the full period of utero-gestation — 
for the foetus is sometimes expelled as early as the sixth month, and 
rarely goes beyond the beginning of the eighth. It is usually found 
to be dead, or so weak as to die very soon after birth. In some 
instances, the liquor amnii is so abundant as to give the woman the 
appearance of being at the full time, though she may not have ex- 
ceeded the seventh month. We have had several such patients under 
our care — in one of these seven dead children were delivered in as 

• S e Chapter u On the term of Utero Gestation." 

28* 



322 UNAVOIDABLE HEMORRHAGE. 

many consecutive pregnancies. This case, with several similar, the 
uterus, &c, were restored to the healthy performance of their duties, 
by mercury, and sarsaparilla, in the unimpregnated interval. 



CHAPTER XXXI. 



HEMOBRHAGE FROM THE SITUATION OF THE PLACENTA OVER THE MOUTH 

OF THE UTERUS. 

1017. Before the world was favoured by the publication of Dr. 
Rigby's treatise on Uterine Hsemorrhagy, it was very illy supplied 
with any treatise that could enlighten it. The absurd theories that 
were published, led but to confusion and uncertainty in the manage- 
ment of this sometimes terrific disease. Before his time, there was 
no regular plan, no definite mode of action, and many were the victims 
to their imperical mode of treatment. But thanks to his lucid de- 
scription and successful mode of treatment, thousands owe their lives.* 
I shall confine my observations on the subject of uterine hemorrhage 
in this place, to the lc unavoidable species," and to those discharges 
of blood which follow the birth of the child ; and will refer my reader 
for an account of such as precede delivery, but in which the placenta 
is not situated over the mouth of the uterus, to my work on the Dis- 
eases of Females. 

1018. The first evidence of the placenta being over the mouth of 
the uterus, may declare itself as early as between the sixth and seventh 
months of utero-gestation. At this time, the neck of the uterus begins 
to unfold itself for the more complete accommodation of the foetus ; in 
consequence of which, a small portion of the placenta will sometimes 
be separated from the Uterus ; this, of course, will be followed by a 
discharge of blood, commensurate with the extent of the lesion, and 
the size of the vessels involved in the separation. 

1019. This discharge may sometimes, by proper management, be 
made to cease, and not to return until the uterus and placenta are 
again forced to separate — then, another slight hemorrhage ensues, 
which may also cease, and not be renewed, perhaps, until the last 
period of pregnancy ; or there may be, as happens sometimes, a con- 
stant stillicidium of a bloody sanies until the last period of gestation. 
Dr. Rigby, who may be justly considered the highest authority upon 
this subject, seems not to have bestowed as much attention to the 
condition of the patient before the full period of utero-gestation, as he 

* We are indebted to Dr. Rigby for the distinction of" accidental and the unavoid- 
able." He has left us but little to add, that is novel on this subject. 



UNAVOIDABLE HEMORRHAGE. 323 

aid to the consequences after that time had arrived, or he would not 
have held the doubtful language he did when speaking of the " time 
and manner" in which the " accidental" and the unavoidable hemor- 
rhage came on: he says u probably that which is occasioned by the 
placenta being fixed to the os uteri, will, for the most part, not come 
on till the full term of parturition, when the uterus begins to dilate 
from the approach of labour," which is contrary to the account I have 
just given, (1018, 1019,) as well as the experience of almost all the 
writers (See Leroux, Kok, Baudelocque, Denman, Burns, &c.) upon 
this subject. Besides, the very economy of the uterus makes the ac- 
count I have given of this accident correct. 

1020. It must not, however, be supposed I insist, that the woman 
will necessarily be subject to these anticipated discharges ; I only wish 
to be understood, that she is unavoidably liable to them, from the me- 
chanism of the uterine expansion. The obliteration of the neck of the 
uterus is not purely a mechanical operation, for it unquestionably 
suffers an organic development at the same time; and much will de- 
pend, as regards the appearance of hemorrhage before the full period 
of utero-gestation, whether the mechanical or physiological process 
shall prevail. Thus, if the neck of the uterus be mechanically operated 
upon, and made to yield faster than the organic development can fol- 
low, a portion of the placenta will be detached, and a discharge of 
blood will follow. When this takes place, the orifice of the uterus 
will be found thinner than usual, and the os uteri rather more open ; 
and this happens, perhaps, more frequently than otherwise, if my ob- 
servations be correct ; that is, I have witnessed more cases of women 
who have had anticipating discharges of blood than those who were 
exempt from them. 

1021. I am aware this does not correspond with the cases given 
us by Dr. Rigby — agreeably to his records, nearly two to one had 
no previous discharge ; while Baudelocque tells us, that the dis- 
charge " sometimes appears as early as the sixth month ; sometimes 
not until the ninth, or even till the approach of labour; but, generally 
from the seventh to the eighth month." When it does not appear 
before the full period of utero-gestation, it must be owing to the 
growth of the placenta keeping pace with the organic development 
of the neck of the uterus; or, in other words, where the mechanical 
agency is inferior to the physiological counteraction. When this 
condition obtains, the neck of the uterus is larger, and its parietes 
thicker than common ; indeed, it has been thought by Duparque, 
that it is not entirely developed* even at full time under suchcircum- 

* This taking place before the complete development of the uterus, is probably 
owing to the hemorrhage being more than commonly severe ; and rendering inlerfe. 
renre n Hi r than usual, and a few days before the uterus has completely de- 

veloped itself. We consider this a'togethcr accidental or contingent. If it be not de- 
veloped, it must be owing to the gradual discharge of blood; the parts being rather 
thicker at the time the hemorrhage takes place, will be readily ac.ouncd for by the 
implantation of the placcuta over the mouth of the uterus. 



324 UNAVOIDABLE HEMORRHAGE. 

stances, and that it is on this account that the hemorrhage does not 
appear until the approach of labour. For he appears to believe, in 
cases of the implantation of the placenta over the mouth of the 
uterus, that the neck of this organ does not develope itself as in 
ordinary cases of pregnancy; and endeavours to prove this, by 
saying he opened the body of a woman who was in her ninth month ; 
the neck of the uterus was very thick, and projected four lines ; that 
he introduced his finger with difficulty in the opening, and ex- 
perienced the like resistance when he attempted to pass it from the 
cavity of the uterus outwards. Now, this proves nothing more than, 
in that case, the development was not complete ; which certainly 
cannot establish the fact he wishes to prove, namely, that in all cases 
of unavoidable hemorrhages, the neck of the uterus is less expanded 
than when the placenta is attached to some other portion of this organ 
than the neck.* 

1022. It is not difficult to believe, that the neck of the uterus, in 
the cases under consideration, is found sometimes thicker than it or- 
dinarily is, at full time ; because in most instances of placental pre- 
sentation, we believe, that hemorrhage takes place before the exact 
period of gestation is completed. Our reasons for thinking so, are, 
1st. That in common cases, which arrive at their full term, but 
where the placenta is attached elsewhere than to the mouth, the 
mouth of the uterus is found to be a flat, plain surface ; and either 
altogether closed, or but little opened, and the edges constituting it, 
thin. 2d. Because this species of hemorrhage is seldom attended with 
pain in its commencement ; and sometimes not at all : which would 
hardly be the case, were the uterus completely developed ; and the 
flooding be the consequence of an entire development, and the abso- 
lute commencement of labour. 

1023. Therefore, when the full time arrives, the woman may be 
surprised by a sudden and an alarming issue of blood, without the 
smallest premonition — for it sometimes makes its approach so silently 
and so rapidly, that the patient may be attacked in the midst of her 
domestic duties, or while in the enjoyment of company. At other 
times it is preceded by slight and distant pains ;f and when this is 
the case, the discharge, for the most part, is neither so sudden nor 
so alarmingly extensive ; for hemorrhage is never so overwhelming 
nor appalling, as when the os uteri silently and rapidly yields, and 
in an instant exposes a thousand bleeding vessels. t 

* Jour. Gen de Med. vol. 29. 

t When this species of flooding 1 is accompanied by pain, it will in general be found 
that the waste is neither so sudden nor so profuse, as when none attends him ; though 
each contraction of the uterus augments, for the time being, the hemorrhage. It 
must, however, be observed, that in proportion to the discharge, will be (caeteris pari- 
bus,) the diminution of the uterine force — and hence the infrequency of natural de- 
liveries in this kind of flooding. Indeed the pain seems almost to cease; or, in other 
words, the contractions cease almost as soon as they commence ; for a certain fulness 
of blood in the uterine vessels seems essential to healthy contraction. 

t This circumstance, however, rarely obtains, but where the woman has arrived 



UNAVOIDABLE HEMORRHAGE. 



325 



1024. The blood flows in an almost unceasing stream, till the wo- 
man becomes much weakened and faint ; coagula may then form, and a 
temporary truce ensue, but this in general is treacherous, and of short 
duration ; especially if pains attend ; for the coagula which had par- 
tially arrested the hemorrhage are now driven away by the contrac- 
tions of the uterus, or by the operation of some other cause, as acci- 
dental as unavoidable, and the discharge is renewed with perhaps 
even increased violence ; and in this way many things proceed, until 
the patient is either exhausted by the waste of blood, or is relieved 
by the judicious and successful interposition of art. 

1025. When the discharge is so extensive and sudden as I have 
just described it to be, no time should be lost before it is ascertained 
whether the flooding proceeds from a separation of a portion of the 
placenta remotely situated from the os uteri, or from this mass being 
placed over it — the symptoms which designate these different situa- 
tions, though, perhaps, pretty strongly marked, are nevertheless, not 
sufficiently accurate, to render a more certain and decided examina- 
tion unnecessary. 

1026. We should, therefore, upon such occasions, always examine 
the mouth of the uterus with great care and caution. In conducting 
this, the finger merely introduced into the vagina, will rarely inform 
us with sufficient accuracy ; the hand should be conducted into this 
canal, that the utmost freedom may be given to this important exami- 
nation. A proper moment, however, should be chosen for this pur- 
pose, that no evil may result from the operation ; for I have just re- 
marked, that a suspension of the discharge is sometimes effected by a 
coagulum within the vagina or mouth of the uterus, which being re- 
moved in making the examination, may renew the flooding ; while 
the blood is flowing, therefore, is the time to make this attempt. 

1027. When the hand has possession of the vagina, a finger must 
be carried within the os uteri ; it should then carefully and with cer- 
tainty, determine the nature of the substance presented to it ; if it be 
the placenta, it can be distinguished from a coagulum, (the only thing 
to which it has any resemblance,) by the following characters: 1st. 
The placenta always presents to the touch the sensation of a fibrous 
structure of pretty considerable firmness. 2d. When this is pressed 
upon by the extremity of the finger, a sensation of tearing an organ- 
ized mass is excited. 3d. It being much firmer in its consistence, 
and offering more resistance to the play of the finger within it, than a 
coagulum. 4th. Its not escaping from the finger, when its substance 
is in some measure broken down by the pressure and free movement 
of it — it can never be mistaken for the membranes. 

1028. In a case of such importance, we should neither permit a 
false humanity, nor a false delicacy to get the better of an imperious 

at, or very near, the full term, and where she has been teased by some previous dis- 
charge. May not the pretty constant, though inconsiderable discharge just noticed, 
contribute to this sudden dilatation of the os uteri, by acting as a uniform local de- 
pletion ? 



326 UNAVOIDABLE HEMORRHAGE. 

duty ; for upon the early knowledge of the species of flooding, the 
woman's life may unquestionably depend. We should, therefore, 
without reserve, state to the friends of the patient our opinion of the 
nature and tendency of her case, and the importance of ascertaining 
it, by a proper examination. This will almost always be acquiesced 
in ; and, if it be properly conducted, it will neither excite severity of 
pain, nor wound the most fastidious delicacy. The hand, for the 
most part, from the relaxation consequent upon a continued discharge, 
will pass without much difficulty ; or it may be made to do so, by 
proper lubrication. 

1029. It is true, indeed, with a first child, and at an incomplete 
period of utero-gestation, there may be some difficulty in passing the 
hand, if the discharge has not been pretty abundant — but in this case, 
the examination is not so immediately important: should it, however, 
be so, from the excess of the hemorrhage, the parts will then be found 
almost always sufficiently yielding to permit the passage of the hand 
without much difficulty. The directions just given for ascertaining 
the particular nature of the hemorrhage, I am persuaded should never 
be neglected, as an attention to them will save a vast expenditure of 
blood in all cases, and in some life itself. 

1030. Having ascertained it to be a placental presentation, the con- 
dition of the mouth of the uterus should next be carefully examined 
— the degree of opening, and its disposition or indisposition to di- 
late, should be marked, for on this much depends. It will be found 
in one of the following situations: 1st, but little opened and very 
rigid; 2dly, but little opened, yet disposed to dilate; 3dly, opened 
to some extent, but very unyielding ; 4thly, opened to the same ex- 
tent, but soft ; 5thly, fully dilated. 

1031. The nature of the case being thus ascertained, the mode of 
treatment is next to be considered. This will necessarily be much 
influenced by the particular condition of the woman, and the period 
at which the discharge may show itself, and its quantity make interfe- 
rence necessary. I have already noticed, that when the placenta is 
situated over the mouth of the uterus, slight discharges of blood may 
take place after the sixth month, as a consequence of the economy of 
the uterus (1018) at this period: when these are moderate, they may 
for the most part, be arrested by the means usually employed for 
flooding, when the placenta is not placed over the mouth of the ute- 
rus ; they should therefore be put into immediate requisition, and the 
patient placed under the strictest injunctions of obedience, and con- 
formity to directions. 

1032. For a discharge of blood at this period is always to be looked 
upon as liable to extreme augmentation; and we should never lose the 
suspicion, that it may arise from the peculiar situation of the placenta. 
We have no certain means by which the " accidental" may at this 
time be distinguished from the " unavoidable," unless it be by a care- 
ful examination — but this is never necessary so long as the flooding is 
moderate. I think, however, I have observed in the " unavoidable," 



UNAVOIDABLE HEMORRHAGE. 327 

that the flow of blood is more sudden and copious in a given time; 
and that it is more fluid and florid than in the u accidental." In the 
commencement, the " unavoidable" is never accompanied by coagula ; 
and when pain attends, the discharge is always increased at each con- 
traction. But in cases demanding precision, these marks cannot be 
relied upon. From the proximity of the bleeding vessels to the os 
externum, die blood will issue so quickly from them, as to appear 
both more fluid and more florid, than in the " accidental," species; 
for in the " accidental," the blood may escape remotely from the os 
uteri, and be obliged to travel slowly through the meshes of the con- 
necting medium of the ovum and uterus ; and hence will appear less 
florid and fluid, and be^more disposed to coagulate than in the " una- 
voidable." 

1033. But coagula will form in the u unavoidable," when the dis- 
charge is about to cease, either by proper treatment, or by the mere 
efforts of nature, and it is in this way that a stop is put to farther 
waste. 

1034. As we cannot determine the situation of the placenta without 
much pain and force, before the full period, when the flooding 
is moderate, it may always be well to treat both kinds as if they were 
cases of placental presentations ; as in doing so we shall be erring on 
the safe side. We should insist upon the most perfect tranquillity, and 
a constant confinement to the horizontal position whenever practicable. 
Blood at this period may be taken from the arm, if the arterial force 
be too great ; cold applications should be resorted to ; and the sugar 
of lead be exhibited in sufficient doses, either by the mouth or by 
enemata as already advised. Kok and others recommend cold astrin- 
gent injections into the vagina : of the utility of these I have much 
doubt — at least, I have never been tempted to employ them. I rarely 
pay any attention to the state of the bowels, unless they be very costive 
— then a mild, warm injection of molasses and water, or soap and 
water, wiil be every way sufficient. I am thoroughly convinced that 
much mischief is sometimes done by the exhibition of even the very 
mildest purgatives ; and the reason will be immediately obvious, when 
we consider the effects of them. I have frequently permitted my 
patients, under treatment for uterine hemorrhage, to be five or six 
days without a discharge from the bowels ; and when I thought it ne- 
cessary to stir them, it has been, for the most part, by means of mild 
injections. . 

1035. Kok also advises the introduction of some substance, such 
as lint or rags, into the vagina, well imbued with a fluid styptic, such 
as a strong solution of alum, or of wine in which alum is dissolved. 
I should place more reliance upon tins latter means than upon the 
former; as it would in some measure act as a tampon, and serve as a 
point fPappui for coagula to form upcn ; for at last we must have 
these form, if the hemorrhage stop without having done much mis- 
chief. 



328 UNAVOIDABLE HEMORRHAGE. 

1036. I have advised bleeding when the pulse is active ; Kok says, 
this is useless, if not injurious, in this kind of flooding. In this I 
cannot agree with him ; and for the following reasons :— 1st. Under 
any kind of active hemorrhage, when the pulse is vigorous, the taking 
away blood from the arm has uniformly been found useful, by pro- 
ducing contraction by unloading the vessels to a certain extent ; and 
more especially, in diminishing the velocity of the blood within them. 
2dly. As, at the period we are speaking of, we cannot decide with 
certainty without manifest violence, from the contingencies just men- 
tioned, that the discharge is from the peculiar location of the placenta, 
we may act, as far as the bleeding is concerned, as if it were an 
"accidental" hemorrhage; especially as the blood detracted will not 
seriously weaken the woman, and as there is a strong probability that 
it may be arrested until the last period of pregnancy by proper appli- 
cations and treatment. 3dly. That at this period the hemorrhage is 
for the most part owing to a mechanical separation of a portion of the 
placenta ; but which will not generally be renewed for some time, as 
the separated vessels, and the other connecting media, possess con- 
siderable elasticity ; therefore time will be given for the formation of 
coagula, provided the proper means be pursued to favour their pro- 
duction ; among which we must reckon bleeding. 4thly. If the dis- 
charge be not produced by external violence, or any other cause which 
will certainly excite the action of the uterus, there is a strong proba- 
bility, that it will cease for the time being ; unless it be improperly 
treated, or unnecessarily provoked. 

1037. Should the body and fundus of the uterus be excited into 
action from any cause, at this period, and the discharge be rather the 
effect of such contractions, than the natural and unavoidable stretching 
of the neck of this organ, we have great reason to fear, that we shall 
not be able to suspend these efforts, so as to enable the woman to go 
the full term of gestation. But we should ever have this intention in 
view, as it may sometimes be happily fulfilled ; and if it be not, it is 
decidedly the most proper mode of treating the complaint. 

1038. In such cases, we would endeavour as quickly as possible 
to interupt uterine contraction ; for this purpose, we should bleed under 
the restrictions just mentioned : we should exhibit the sugar of lead 
with laudanum, as frequently as the exigencies of the case may require ; 
and by enemata, I think, is much the most prompt and efficacious 
mode of administering them. From a scruple to half a drachm of this 
salt, with a drachm of laudanum, and a gill of water, may be thrown 
up the rectum every hour, or more seldom, as occasion may call for 
them. All the auxiliary plans I have already recommended should be 
put in requisition, and their full adoption ridgidly enforced. 

1039. Should these means moderate the discharge, and the blood 
be found disposed to coagulate ; and if, at the same time, uterine con- 
tractions have ceased, or even considerably diminished, we may be 
encouraged to persevere in the use of these remedies, and entertain 



UNAVOIDABLE HEMORRHAGE. 329 

an expectation of ultimate success. The introduction of a moderate- 
sized tampon of sponge at this time, as a mere point (Pappui, is highly 
useful; for, without some such support, the coagula maybe discharged, 
and the hemorrhage renewed. 

1040. The artificial support for coagula, which I have recom- 
mended above, (1039,) is of more consequence than we would at 
first imagine. It permits the thinner parts of the blood to escape 
through the meshes of the sponge, by which means the coagula are 
rendered more firm and tenacious ; besides diminishing, by acounter 
action, the influence of the vis a tergo, which is constantly operating 
to throw them off. 

1041. I am aware, that some rely upon the coagula without the 
tampon ; and I must admit, that they have occasionally been suffi- 
cient to save the woman's life ; a case of this kind is related by Le- 
roux ; (Observations, p. 258 ;) but he expressly declares they are not 
to be relied upon. The sudden movement of the woman's body, for 
even necessary purposes ; uterine contraction ; the escape of the wa- 
ters, &c, may all serve to disturb the coagulum which has arrested 
the hemorrhage. But the most important use of the tampon under 
these circumstances, remains to be mentioned ; which is, that it causes 
the coagulation of the blood, merely by presenting a surface favoura- 
ble to this change, long before this disposition would spontaneously 
show itself; for in general, this effect is not produced, but when the 
woman is much exhausted, or by the rather tardy, though successful 
influence, of the remedies previously employed.* 

1042. Should our endeavours, however, fail to arrest the discharge, 
we should, without farther loss of time, ascertain the condition of the 
os uteri, and then proceed precisely as if the woman had arrived at her 
full time when the hemorrhage commenced ; for it will now be found 
that the cases are reduced exactly to the same condition, and will re- 
quire the same mode of management ; of which I shall speak more 
at large presently. 

1043. A woman may escape these anticipating discharges until 
she complete her full term ; but at this time it will be seen that the 
uterus cannot expel its contents without necessarily exposing the pa- 
tient to the most imminent risk. So alarmingly profuse, and so de- 
cidedly dangerous are these discharges in some instances, that a few- 
minutes are sufficient to exhaust the strength, or to deprive the wo- 
man of life. 

1044. I once witnessed a case in which there was discharged from 
the uterus, in the course of about fifteen minutes, a full half gallon of 
blood ; and was sent for in another instance, where the woman had 
expired before my arrival, though there had not, as the midwife as- 
sured me, more than half an hour passed from the commencement of 

* Mr. Bums assures us, he never saw a case which required delivery during the first 
paroxysm, if a proper treatment had been adopted. — Principles of Midwifery, 5th ed. 
p. 323. 

29 



330 UNAVOIDABLE HEMORRHAGE. 

the flooding to its fatal termination. These are, however, extreme 
cases, yet they show how suddenly and certainly they may be fatal. It 
is confessed, on all hands, that no accident attendant upon concep- 
tion is equally menacing as the unavoidable hemorrhage ; and it also 
emphatically declares to the physician, that much depends upon him 
that it shall not be very often fatal. It is one of those extraordinary 
cases, in which nature does less for the preservation of the individual, 
than almost any other. 

1045. This does not arise so much from want of exertion on the 
part of nature, if I may so term it, as from the almost entire incom- 
patibility of giving birth to the child, and protecting the woman 
against flooding, at one and the same time. Yet we learn, from such 
authority as cannot be doubted, that the woman, left entirely to her- 
self, will not always perish. The means, however, which nature em- 
ploys to procure this immunity offer neither a useful practical hint, 
nor the smallest inducement to imitate her ; for they are so entirely 
contingent, and sometimes so long withheld, the woman, from her 
great exhaustion, can scarcely be said to profit by the interposition. 

1046. Baudelocque* says the woman may be preserved u when 
the orifice is fully dilated, and the mass separate entirely from it, and 
be so far removed from one side, that the membranes may present. 
The membranes may then tear spontaneously, and delivery be per- 
formed naturally, if the woman, notwithstanding her loss of blood, 
still preserves sufficient strength, as has sometimes happened." Le- 
roux,f by the formation of coagula, and the spontaneous action of 
the uterus. Smellie,| to the entire separation of the placenta, rupture 
of the membranes, and the placenta being first delivered, &c, &c. 

1047. From this it w T ould appear that in some rare instances the 
woman has been saved by the natural agents effecting the delivery 
before she was too much exhausted; but we do not profit by the 
knowledge of the manner in which this was performed. It is, there- 
fore, now completely established, that the only chance the woman 
has for life, is by a well-timed and well-conducted delivery in every 
case, (c ceteris paribus,) of placental presentation. 

1048. Though it be universally admitted that there is but one mode 
of proceeding in the case we are now considering, yet it is not so 
generally conceded that the success of that more essentially requires 
that the delivery be properly timed, and as properly conducted. All 
who have written upon this subject, seem to agree in one of the posi- 
tions; namely, that delivery is absolutely necessary; but many, and, 
indeed, I may add too many, have been regardless of the condi- 
tions which serve to render this operation availing. 

1049. The success of the operation of turning for the relief of this 
species of hemorrhage, must depend upon its being performed under 

* System of Midwifery, Vol. II. par. 986. 

t Observations, &c., p. 306. 

t Midwifery, Vol. II. Col. 18, No. 3. Cases, Nos. 3, 4, 5, 6 7. 



UNAVOIDABLE HEMORRHAGE. 331 

the proper conditions of the mouth of the uterus. We have already 
insisted on this when treating of " turning," therefore, shall not repeat 
here the rules we laid down as essential to success, whenever this 
operation is performed. 

1050. The time when we shall attempt delivery is of the greatest 
moment, and deserves particular investigation. Dr. Den man says, 
" It would be of great advantage in practice, if some mark were dis- 
covered, or some symptom observed, which would indicate the pre- 
cise time when women with hemorrhages of this kind ought to be 
delivered;" but declares, "we do not at present know any such 
mark." Yet almost immediately after decides, that "whenever the 
case demands the operation, on account of the danger of the hemor- 
rhage, the state of the parts will on this account always allow it to be 
performed with safety, though not with equal facility. 

1051. If this be true, we are certainly in possession of what Dr. D. 
thought so great a desideratum — for if the parts be in condition to 
turn with safety, it is certainly all that is required, when " the danger 
of the hemorrhage demands the operation." For if the parts permit 
turning without risk, they must be in a dilated or a dilatable state, 
and this is all that is or can be required when the condition of the 
flooding " demands the operation." Then we have a rule which is 
never failing, when this condition of the parts obtains, if it be true that 
this can always be done with safety, if not with equal facility. 

1052. Now, it is of importance to inquire whether turning can al- 
ways be performed with safety when the parts are in a condition to 
permit it ; for upon this much depends. It would seem agreeably to 
this position, that the whole risk the woman runs in these cases, arises 
from the " state of the parts" opposing the introduction of the hand; 
and when they do not, that turning may then be performed with safety 
— experience, however, constantly contradicts this unqualified opinion, 
for the woman may be so far reduced that she may expire before the 
operation is completed, or very quickly after.* 

1053. Besides, the manner in which we find the opinion stated by 
Dr. D. would lead to the persuasion, that so long as the os uteri was 
not opened, there could be no danger, whatever might be the quantity 
discharged, than which nothing can be more unfounded ; for it is a 
well-known fact, that the powers of the uterus may be so far impaired 
as not to perform this office, even at the last moment of existence. 
In this I am supported by the experienced Dr. Rigby,f who declares, 
that were " this rule invariably adhered to, in some cases, it would 
be attended with danger, as we might wait for the opening of the 

* Of th ; s we have ample proof, in cases 53, 81, 82, 83, 98, &.C., of Rigby, in each 
of which the condition of the parts easily permitted turning, but not with safety. But 
I am clearly to b^ understood that I attach no censure to the operation ; for I am of 
opinion it wis the only thing that could be done to give the woman a chance — and I 
have m doubt, it was properly performed. But these eases go to prove the incorrect, 
ness of the posi'inn I am now examining. 

t Essay, 6th. ed. p. 40. 



332 



UNAVOIDABLE HEMORRHAGE. 



uterus till it was too late to relieve the woman by turning the 
child." 

1054. This will be very readily understood, when it is recollected, 
that the opening of the uterus mainly depends upon the longitudinal 
fibres acquiring the mastery of the circular; but when the uterus is so 
far exhausted of contractile power as to remain passive, or nearly so, 
we shall always find the os uteri closed, (unless previously distended 
by an exertion of its powers,) though it may be most easily dilatable, 
I may perhaps even acquiesce in the explanation of Dr. Rigby* upon 
this subject, who supposes that the position of the placenta may serve 
to keep the uterus closed by surrounding its mouth, by the attach- 
ment of its fibres to this part, which is now perfectly passive and un- 
resisting — this is both ingenious and probable. 

1055. 1 must now make a distinction of great practical importance, 
that has never, so far as I know, been pointed out ; which, if it be just, 
(and my experience gives me every reason to believe it is,) will in 
some measure serve to reconcile the conflicting opinions of writers 
upon the subject of the time when it would be invariably proper to 
attempt the relief of the patient by turning — it is simply this, that there 
is a most material difference between the dilatation of the os uteri, or 
even its dilatability, when effected by the natural powers of this organ, 
and that passive or quiescent condition, which results from the languor 
of death. 

1056. The one is the result of its organization, when its powers are 
not too much impaired or prostrated by disease ; while the other is a 
syncope, if I may so term it, produced when these powers are ex- 
hausted, by an excessive waste of blood. This distinction must con- 
stantly be kept in view; for on it depends the rational mode of treat- 
ing this formidable complaint: for if it be not, we prescribe both 
uncertainly and empirically. An attention to the one leads us to 
husband with the utmost care the strength and vigour of the patient ; 
while the other makes us regardless, if not prodigal of it : the one is 
almost always crowned by success, the other leads almost constantly 
to a doubtful issue. 

1057. We can readily account, with this distinction in view, for 
the difference of success in the operation of turning. When per- 
formed after the dilatation of the uterus has been effected by the 
natural agents, it has perhaps almost always been attended by the 
much desired issue ; but when performed after the flaccidity of ap- 
proaching death had ceased to make it difficult, it too often has been 
followed by the loss of the patient. Under this impression, I should 
say, that when the os uteri was either dilated or rendered dilatable 
by the operations of this organ ; and before the strength of the pa- 
tient was materially impaired, that then, and then only, was the de- 
sirable time to operate ; but if circumstances prevent advantage 
being taken of the proper moment, and nothing but a choice of diffi- 

* Essay,. 6th ed, p. 40* 



UNAVOIDABLE HEMORRHAGE. 



333 



culties remains, we should certainly attempt to snatch the woman from 
her impending fate; but this should be under the cautions already 
suggested. 

1058. I will attempt to put this subject in a clearer point of view, 
by considering what ought to be attempted for the relief of the pa- 
tient under each of the conditions of the uterus pointed out above, 
(1030 :) and which necessarily comprehends every state of which it 
is at this time susceptible. 



Sect. I. — 1. Where the Uterus, is but little opened , and is very rigid. 

1059. In the condition of the uterus here designated, all the evils 
which can attend the forcing of a rigid os uteri, would take pface by 
an attempt to deliver; it should, therefore, not be thought of. In- 
deed, this has ever been a subject of great embarrassment to writers 
upon ibis subject; and makes them in many instances at variance 
with themselves ; or they give their directions so obscurely, and so 
hesitatingly, as to confound the judgment of the young practitioner.* 
It has given rise to two modes of proceeding, each of which is 
equally wrong. 

1060. The first is to force the uterus, how T ever rigid, provided 
a finger can be introduced. , I have already said much upon this 
plan, and shall only add in proof of it a quotation from Dr. Rigbyf 
every way illustrative of the impropriety of this outrageous practice. £ 
"In recommending early delivery, I think it right, however, to ex- 
press a caution against the premature introduction of the hand, and 
the too forcible dilatation of the os uteri, before it is sufficiently re- 
laxed by pain or discharge ; for it is undoubtedly very certain that 
the turning may be performed too soon, as well as too late, and that 
the consequences of the one may be as destructive to the patient as 
the other. I am particularly led to observe this, as I have lately 
been informed from very good authority, (namely, a gentleman to 
whom one of the cases occurred,) of three unhappy instances of an 
error of this sort which happened some years ago to three surgeons of 
established reputation, who, from the success they have met with in 
delivering several who were reduced to the last extremity, were en- 
couraged to attempt it where but little blood had been lost, in hopes 

* For an instance of this kind, I may cite even Mr. Burns himself— he tells us, in 
one sentence, " if the hemorrhage have been or continues to be considerable, we must 
not wait until the oa uteri be much dilated, as we thus reduce the woman to great 
danger, and diminish the chance of recovery." A few lines farther in the same page, 
he says "a prudent practitioner will not violently open i>p the os uteri, but will use the 
plug," A little farther on, he declares, "he, (a prudent practitioner,) will not allow 
his patient to lose much blood, or have many attacks ; he will deliver her immediately 
for we know that whenever that is necessary, that it is easy, the os uteri yielding to. 
his cautious endeavours." — Prin. 5th ed.p. 324. 

t Essay on Uterine Hemorrhage, 5th ed. p. 40. 

t See Chapters " On the Causes, which may render a natural, a preternatural La> 
bour ;" and on " Turning." 

29* 



334 UNAVOIDABLE HEMORRHAGE. 

that their patient's constitutions would suffer less injury, and their 
recovery be more speedy ; which, till the experiment was made, was 
a very reasonable supposition — the women died, and they seemed 
convinced that their deaths were owing to the violence of being de- 
livered too soon, and not to the loss of blood, or any other cause." 

1061. The other is, to permit the flooding to proceed until the 
woman shall be so much exhausted as to render the uterus pliant. 
Br. Denman, as I have just noticed, supposed that when danger 
created a necessity for delivery, that then, from the loss of blood, the 
uterus would permit it with safety. Dr. Rigby says, that when the 
uterus contracts firmly round the fingers, we should desist from any 
attempt to deliver, and wait till the part be more relaxed by pain or 
discharge; and adds, " as an encouragement, that we may safely suffer 
a wom%n to lose more blood, the contraction may certainly be looked 
upon as a proof that there still remains a considerable portion of ani- 
mal strength, and that she has not been so much affected by the loss 
as we before imagined." 

1082. I cannot recommend this plan, though it be the advice of 
the first authority upon this subject. I am convinced, from both 
reason and experience, that it is seldom or never necessary ; and is, 
perhaps, always injurious. To save the woman an ounce of blood, 
is a duty : to save her forty ^ or, perhaps, much more, is still a 
greater one. To follow, then, the speculation of Dr. Denman, or 
the advice of Dr. Rigby, would be widely departing from these 
duties. I do not, I cannot adopt either. 

1063. What is essentially important to be done in this case ? 1st. 
To save as much and as quickly as we can, the farther expenditure of 
blood. 2d. To obtain, as soon as the natural powers will effect it, 
ihe dilatation or dilatabi-lity of the uterus. 3d. To deliver then with 
as much speed as is consistent with the welfare of both mother 
and child. 

1064. The first and second of these indications are, as far as I 
have witnessed for the last thirty years, readily complied with by 
the use of the tampon, and the other auxiliary remedies. If they 
be instantly had recourse to,, the discharge will almost immediately 
abate ; or in a short time be so diminished as to give no immediate 
concern. By this means we not only stanch the hemorrhage, but 
gain most important time; for during this truce, the natural agents 
of delivery will effect the desired relaxation of the os uteri. 

1065. This plan, I believe, originated with Leroux ; and has been 
adopted with entire success by myself for many years past. It has 
also the sanction of Mr. John Burns, who recommends it by saying, 
u a prudent practitioner will not violently open the os uteri at an 
early period, but will use the plug, until the os uteri become soft and 
dilatable." (See note to par. 1059.) It is true, Gardien thinks the 
plug will do harm, by exciting the uterus, and thus increase the 
separation of the placenta — but this is theory; it is not consonant 
with experience. 



UNAVOIDABLE HEMORRHAGE. 335 

106G. The following case, selected from several of a similar kind, 
will place in a clear point of view the promptness and efficacy of 
this plan. Mrs. , while looking out of her window, was sud- 
denly surprised by a profuse discharge of blood from the vagina. 
Before I arrived, though near at hand, more than half a gallon of 
blood was expended upon the floor and in a pot. The patient was 
upon the bed, pale, feeble, and excessively alarmed. I examined 
her immediately, and found the uterus rigid, and the placenta pre- 
senting. She had no pain; nor had she any previous to the irrup- 
tion of blood. The discharge was very profuse and exhausting ; 
but as the os uteri was undilated and rigid, I introduced the tampon, 
and secured it within the vagina by a compress upon the external 
labia with a T-bandage. The flooding ceased immediately, and 
there was nothing passed the os externum but some of the thinner 
parts of the blood. After the tampon had been applied about four 
hours, pains commenced pretty briskly, and in about two hours 
more, they were of considerable force, so much so as to press against 
the external compress with some violence. I now removed the 
tampon; and the os uteri was found sufficiently dilated to allow the 
hand to pass with entire freedom ; and the delivery was quickly 
effected, with safety to both mother and child. 

1067. For the successful fulfilment of the third, and last indica- 
tion, it is necessary that the practitioner should be well acquainted 
with the condition of the uterus, at the moment he is about to com- 
mence the operation, that is, he should know how far he may rely 
upon its co-operation, or how far it may be capable of that degree 
of contraction which shall secure the woman against a farther loss 
of blood. This can only be presumed, from taking into view the 
quantity of biood lost; the debiiity or exhaustion it has occasioned; 
and the degree of force the uterus may exert, at each return of 
pain. 

10G8. If it be found, that the quantity of blood is not excessive ; 
if the degree of exhaustion be not alarming ; and if, above all, the 
uterus manifest considerable vigour; the delivery may be accom- 
plished in much shorter time, and with much greater promise of 
success (especially to the child,) than if the contrary of these ob- 
tain — in the latter case, the delivery must be conducted with the 
utmost caution, that the uterus may not be too suddenly emptied, 
and augment the danger to both mother and child. I shall again 
advert to this subject, when I come to describe the manner of con- 
ducting the operation of turning, or effecting the delivery in such 
cases. 



Sect. II. — 2. When but little opemd, but disposed to dilate. 

1069. In this situation of the uterus, but few obstacles to turning 
or delivery will present themselves; since, if the necessity of the 



336 UNAVOIDABLE HEMORRHAGE* 

case require the operation, the great objection to it is in some 
measure removed ; for this disposition to yield to a moderate force, 
will secure the woman against an excessive loss of blood, by taking 
advantage of it, and effecting the delivery in proper time. 

1070. But it must be recollected, that though the uterus may be 
disposed to yield, with even a moderate force, to a certain extent, 
if it be slowly and judiciously applied, yet it may refuse to relax 
beyond this, or to such a degree as would not embarrass the opera- 
tion ; nor can it sometimes be made to yield more, unless a danger- 
ous or reprehensible force be applied.* 

1071. In a case of this kind, we should gain time by the employ- 
ment of the tampon, as directed above, and not subject the woman 
to unnecessary risk, by attempting to overcome the resistance of the 
uterus by violence ; and it must also be recollected, that, in cases like 
these, cases so replete with risk, we are to devote ourselves to the best 
interests of our patients — 'they should never be subjected to the chance 
of a fatal hemorrhage, by our leaving them even for a short time ; for 
neither the plea of other engagements, nor a persuasion they can re- 
ceive no injury during a short interval of absence, can justify our 
withdrawing ourselves from them. I could cite a number of instances 
in support of this, were such confirmation necessary. If it be judg- 
ing proper to employ the tampon, we should wait patiently for its 
effects; but we should wait at the bed-side, or near the patient, that 
we may take immediate advantage of any favourable change in the 
condition of the parts, for which we w T ere so anxiously looking ; or 
guard against any unfavourable contingency, that might suddenly or 
unexpectedly arise. 

1072. Sometimes indeed, the os uteri appears entirely closed, though 
at the same time it is easily dilatable ; this case should not be con- 
founded with the one just considered ; for here the woman may be 
readily delivered, as far as the condition of the mouth of the uterus 
is concerned, should the urgency of the case require it. This situ- 
ation of the uterus, for the most part, only takes place when the wo- 
man is nearly exhausted, and its powers so far impaired, that the 
agents for the absolute dilatation of its orifice are incapable of the 
effort. Should w T e wait for the expansion of the os uteri in such in- 
stances, we should wait in vain ; and, perhaps, even be made wit- 
nesses of the death of the patient.f 



Sect. III. — 3. Open to some extent, but very unyielding. 

1073. Were we to consult authors upon the point of practice in 
this condition of the uterus, we should find too many sanctioning 
forced delivery. I might employ the arguments here, that I have 

* Leroux, Mariceau, Rigby, &c. 

t See Rigby on Uterine Hemorrhage. 



UNAVOIDABLE HEMORRHAGE. 337 

already used against any violence being committed upon an unyield- 
ing uterus ; for it may sustain as much injury in the condition sup- 
posed here, as in the instances I have been considering ; for if the 
opening be insufficient to permit the hand to pass without the em- 
ployment of force, it will certainly be insufficient to allow the foetus 
to pass without using much more ; it should, therefore, be considered 
full as ineligible to operate in this case, as in the two I have just 
noticed. 

1074. Besides, there is less excuse for being precipitate in this 
case ; since, the desired relaxation will most probably soon ensue, as 
the os uteri has already yielded to some extent ; therefore, by giving 
it a little more time, and by employing the tampon, the delivery may 
be accomplished without either violence or risk. 

1075. Had we no command of the hemorrhage, we perhaps might 
be justified in the employment of force ; as it would then be a der- 
nier resource ; but as we can certainly control the discharge by the 
tampon, we should be inexcusable to attempt delivery until it has 
been properly tried, and it has failed. 

1076. But let not this case be confounded with the condition next 
to be mentioned. For, when it is ascertained that the uterus, though 
opened to some extent, is, notwithstanding, very unyielding, a young 
practitioner may, in the confusion and embarrassment created by the 
exigency of the case, easily run into the error, that this case must be 
treated as the one about to be considered. To avoid this error, he 
should carefully examine the condition of the os uteri, by placing, or 
.rather hooking a finger within it, and drawing the edge towards him ; 
if it readily yield, he may be pretty certain it will stretch by a well- 
directed force within its circle. 

1077. But, in conducting this examination, T must caution him 
against a mistake he may readily make, if he be not put upon his 
guard ; which is this — he may mistake the movement of the whole 
os uteri for a portion of it ; but this error may, without difficulty, be 
corrected, by deliberately performing the examination, and attending 
strictly to the following marks : if a rigid os uteri be drawn, say, to- 
wards the pubes, its edge under which the finger is placed will re- 
tain the feeling of rigidity ; and if the finger be made to pass round 
the whole of its circle, it will be found to be uniformly stiff and 
round, and not any, or very little enlarged by the efforts made upon 
it ; but, on the other hand, if the os uteri be dilatable beyond the 
size we suppose it to be by the touch, it will be found soft, and will 
yield without difficulty to the effort made to stretch it ; and if the 
finger be then allowed to pass round it, it will be perceived to be of 
a lengthened shape, and to have been entirely obedient to the force 
employed to draw it forward. 



338 UNAVOIDABLE HEMORRHAGE. 



Sect. IV. — 4. Where opened to the same extent, but soft. 

1078. I have just declared an error may be committed by an in- 
experienced or timid practitioner, in this condition of the uterus, and 
have pointed out the method by which it may be instantly corrected ; 
it, therefore, behooves him not to neglect to entirely satisfy himself, 
as to the situation of the os uteri, before he finally makes up his 
opinion on the proper mode of practice. 

1079. A careless or ill-conducted examination may, in this in- 
stance, lead to the loss of the patient ; for by mistaking the absolute 
diameter of the uterus for the possible, he may delay the operation 
so long as to render it totally unavailing ; for I perfectly agree with 
Dr. Rigby, (Rigby, p. 42,) that, however important it may be as a 
general rule, that the uterus must be opened to the size of a shilling, 
or a half crown, before any attempt is made to introduce the hand ; 
yet, if this rule be rigidly enforced, " it would, in some cases be 
attended with danger, as we might wait for the opening till it was 
too late to relieve the woman by turning ; and for this reason it 
seems right we should sometimes be as much influenced by the os 
uteri being in a state capable of dilatation without violence, as by 
its being nearly open." (Rigby, p. 43.) In my directions for the 
management of cases in the second condition of the uterus, I noticed 
this situation of the organ and remarked that it usually occurred 
when the woman had flooded to excess — but I have known at least 
two exceptions to this. 



Sect. V. — 5. Where fully dilated. 

1080. When a case presents itself with this condition of the 
uterus, there can be no hesitation about the proper mode of pro- 
ceeding, if the exigencies require instant interference ; for in this 
case all objection is removed to the operation of turning, so far as 
any mechanical injury to the uterus is to be feared — but this is a 
rare case ; and when it does occur, it seems to happen only under 
the following circumstances : — 1st. In those women who are wont 
to have very rapid and very easy labours. 2dly. Where the edge 
of the placenta extends over the os uteri, and where in consequence 
of this, the hemorrhage has not been sufficient to seriously injure 
the contractile powers of the uterus, though rather profuse. 3dly. 
Where the pains have been so rapid and powerful as to suddenly 
dilate the os uteri, and cause the head to carry the placenta some 
distance before it. 

1081. In the first case, (1080,) the hemorrhage will be of the 
most profuse and alarming kind ; and if the woman be not very 
quickly aided, she will most probably die ; this happened with the 
poor woman who died before I got to her assistance : in this situa- 



UNAVOIDABLE HEMORRHAGE. 339 

tion of things not a moment is to be lost; turning must be instantly 
had recourse to. 

1082. In the second instance, the discharge, though, perhaps, very 
free, is never so overwhelming as in the first ; for the edge of the 
placenta may be passed over the os uteri but a small distance ; the 
flooding will, of course, be in proportion as this may be more or 
less extensive: in these cases the membranes may even present, 
rupture spontaneously, and thus save the woman ; here the natural 
agents may accomplish the delivery — but more of this by and by. 

1083. In the third case, the flooding will be perhaps, for a period, 
as alarming, and for the time of its continuance as profuse as in the 
first — but the uterus acting promptly and vigorously, the head of 
the child is made to press so effectively upon the mouths of the 
bleeding vessels, as to arrest the hemorrhage. (Baudelocque, Le- 
roux, &c.) In this instance we must act according to circum- 
stances ; if we see the patient during the time of her profuse flood- 
ing, we should not hesitate a moment to deliver, even though the 
pains be brisk ; for it is entirely contingent that the discharge will 
be stopped by the intervention of the head. But should we not see 
the patient until by the progress of the head, the bleeding is arrested, 
we should not interfere, but commit the case to nature. 

1084. It has been recommended by some, among these, Dr Blun- 
dell, lately to rupture the membranes, in the expectation of stopping 
the hemorrhage, as frequently happens when the placenta is not 
fixed at the mouth of the uterus — but this should never be done; 
especially before the uterus is well dilated, or easily dilatable, and 
for the following reasons; — 1st. Because they cannot be reached 
without great difficulty, in some instances, and in these cases, when 
they are reached, it is either by piercing the centre of the mass, or 
separating a portion of the placenta, and thus increasing the extent 
of the bleeding surface. 2dly. When they are pierced, and the 
waters evacuated, it will very rarely stop the hemorrhage. 3dly. 
When it does not do this, we are sure to have the difficulties of 
turning increased. 4thly. Should the flooding for the moment cease 
after the discharge of the waters, it is sure to return as the pains 
increase, and as the uterus expands. The only exceptions to these 
rules, are the cases just mentioned above, where the membranes 
present themselves in part. (1082.) 

1085. Baudelocque assures us he has seen but one case, where 
the hemorrhage ceased after the discharge of the waters; and in 
that case the placenta was first delivered by a midwife, and the 
head of the child was made to press so firmly on the mouths of the 
bleeding vessels as to stop the hemorrhage, (System, Vol. Jl. par. 
982.) 

1086. It may be inquired, what plan of relief is to be pursued in 
placental presentations, when they happen at or near the sixth 
month ? These when they occur, are truly embarrassing cases; as, 
for the most part, the uterus is not sufficiently enlarged to admit 



340 UNAVOIDABLE HEMORRHAGE. 

the hand to turn, and the hemorrhage is sometimes very alarming ; 
the great risk in this situation of things, arises from the want of 
disposition in the os uteri to dilate, and, before this is accomplished, 
the woman sometimes succumbs from the unrestrained flow of 
blood. 

1087. But women in this situation, even when unaided, do not 
necessarily die ; nature being now and then competent to the task of 
delivery. (Rigby, Leroux, &c.) I may remark, as a general rule, 
and as a consolatory circumstance, that nature, if not interrupted, or 
when the best chance is given her, will almost always effect the ex- 
pulsion of the ovum, previously to, or soon after the sixth month, 
without the manual interference of the accoucheur — for the most part, 
then, in such cases, our attention should be directed to the diminution 
of the hemorrhage, by such palliatives as we have constantly in our 
power ; among these the tampon stands foremost. 

1088. This remedy should be employed early in such cases, as it 
will, by proper management, save a prodigious expenditure of blood; 
and we gain by its application, important time; time that is essential 
to the successful delivery of the foetus — for by the tampon the woman's 
strength is preserved ; pain is permitted to increase; and eventually, 
though tardily, the os uteri is dilated ; the placenta and foetus thrown 
off; and the flooding almost immediately controlled. Other means 
should be advised, such as cold applications and the free use of the 
acetate of lead ; but above all, if the uterus be disposed to dilate, the 
secale cornutum. These may powerfully aid the general intentions, 
and render the operation of the tampon more certain. 

1089. Mauriceau and others attempted the relief of the woman by 
manual exertion under such circumstances ; but I should, neither from 
the history of their cases, nor my own experience, be tempted to re- 
commend their plan, I am persuaded, that the temporizing mode I 
have just suggested, is the proper one to pursue — Leroux long since 
adopted this method, and I have for many years but trod in his foot- 
steps ; and it is but just and proper to add, I have had abundant 
reason to be satisfied. Besides, in this opinion all the best writers 
concur. 

1090. Dr. Rigby, though by no means confident of the efficacy of 
the tampon, confesses, in the cases 1 am now considering, it might 
be used with propriety. Had he put this plan in execution, I am 
persuaded he would have been satisfied with its effects, and would 
unquestionably have prevented his giving the hazardous advice, " to 
wait for relaxation," by permitting the patient to flood, until the col- 
lapse almost of death should effect it. 

Dr. Merriman's hypothetical objections against the use of the tampon 
in this species of hemorrhagy, are scarcely deserving of notice; be- 
cause, so far as we have experienced, or can learn, the evils depre- 
cated by him, have never taken place. We have employed this 
means upon numerous occasions, in both the accidental and unavoid- 
able hemorrhages, and we can most truly say we have never seen the 



UNAVOIDABLE HEMORRHAGE. 341 

use of the tampon followed by the consequences he so much appre- 
hends; for though the uterus might be distended by blood, were it 
influent within its cavity, we have nothing to fear of this kind when 
it does not. We would ask how blood was to pass into the cavity 
of the uterus, when it only flows over the posterior surface of the 
membranes? For when the uterine vessels are exposed by a separa- 
tion of a portion of the placenta, the blood flowing from this denuded 
portion escapes through the os uteri, and not into the uterine cavity : 
if, then, the tampon prevents the discharge through this opening, it 
can only accumulate behind the membranes by partially separating 
them ; and this will be but to a small amount, as they are kept pretty 
tense and resistant by the counteracting force of the liquor amnii. It 
is true, Dr. M's. fears might be realized after the delivery of the child, 
were a tampon introduced into the vagina; but in such cases, we 
never employ this remedy. 

1091. Experience has often convinced me, that the relaxation of 
the os tincce, so desirable in the cases I am now considering, will be 
as certainly achieved by time, as by this excessive expenditure of 
blood : and this time may be procured by the interruption of the flood- 
ing by the tampon. When we effect this, we assuredly gain a great 
deal — strength is saved by saving much blood: and the woman's 
future safety is almost ensured; for as a general rule we may declare, 
that when no violence is committed upon the uterus by an attempt at 
forced delivery, the only thing to be apprehended, is the consequences 
of the hemorrhage. 

1092. When the woman is farther advanced, say at the seventh 
month, artificial delivery may most generally be effected.* Provided 
we do not destroy the advantages this more advanced period gives 
us, by improper treatment ; — for instance, by rupturing the mem- 
branes, and the consequent discharge of the waters; this should 
therefore be especially guarded against. An attention to this point 
in these cases, is more important than at the full period ; notwithstand- 
ing the advice of some accoucheurs to the contrary. 

1093. It now only remains to describe the mode of effecting the 
delivery, when it is judged proper it shall be performed. In doing 
this, we can give only general directions for placing the woman, as 
we cannot, from extreme weakness, or from other causes, always 
command the most proper or convenient; it may nevertheless be well, 
when we have a control over circumstances, to point out that which 
in our opinion is best— that disposition of the woman's body, which 
will give us the most entire command of the uterus and its contents, 
will certainly be the most convenient for the accoucheur, and also the 
safest for the woman, and this position is upon the back ; as has already 
been directed, (732,) &c. 

1094. Many accoucheurs, and especially the British, recommend 
the patient to be placed upon the side; I have ever found this posi* 

* Lcroux, Rigby, &c. 

30 



342 UNAVOIDABLE HEMORRHAGE. 

tion less convenient than the one just suggested ; and have therefore 
always adopted it, where the situation of the woman would permit a 
choice, without injury. The advantages of this position are, first, 
we may employ either hand as may be most convenient to the practi- 
tioner, without changing the situation of the patient. Secondly, we 
always have one hand at liberty to co-operate with the introduced 
one, by placing it upon the abdomen. Thirdly, we can pass the 
hand more readily in the axis of the superior strait, by having the 
perineeum free over the edge of the bed. Fourthly, we can regulate 
the discharge of the liquor amnii, ad libitum, a matter sometimes of 
great moment.* But it must be remembered, we are never to at- 
tempt to procure these advantages by moving the patient, when that 
movement would be injurious to her: therefore, when she is very 
weak or faint, we must operate as well as we can in the position 
w r e find her ; this is sometimes very awkward and inconvenient, but 
these are of no consideration, when her life, perhaps, is to be put in 
competition with our ease. For the most part, there is not much to 
be apprehended from merely changing the woman from her back, 
should she be lying upon it, to her side ; but a greater change might 
be very mischievous ; we are therefore frequently obliged to do this 
before we can operate, as it would be almost impossible to turn, 
when the patient's back and hips are at some distance from the edge 
of the bed.f 

1095. Should circumstances, or choice induce me to deliver from 
the side, I always give a preference to the left, provided an election 
can be made. The hips should be drawn near to the edge of the bed, 
and made as salient almost as may be, by the flexion of the body, 
and the drawing up of the knees. In this position the left hand is to 
be used, as with the right it would be very difficult to operate, owing 
to the axis of the superior strait being very much in advance. If, on the 
right side, the right hand should be employed, and for the reason just 
stated. 

1096. The woman being properly placed, (if in our power,) the 
hand should be gradually and gently introduced into the vagina, and 
then into the mouth of the uterus, separating the placenta and mem- 
branes from it as it advances towards the fundus-^- when arrived there, 
the membranes should be broken by pressing firmly against them ; 
but the waters should not be permitted to escape but at our pleasure. 

1097. We can command this almost always, as our arm fills up 

* Dr. Ryan,* seems a Httle surprised at this direction, and asks, "How can this 
fluid escape, if the wrist or arm fills the vagina ? It cannot, if the arm should lite- 
rally fill the vagina — but it never does so, strictly, agreeably to my own experience, 
but what the liquor amnii would escape, if the membranes be pierced near the os uteri. 
But this precaution is recommended only in the unavoidable hemorrhage. 

t We must always remember to have pressure' made upon the abdomen by a judi- 
cious assistant, when we deliver the woman upon the side ; as we cannot in this posi- 
tion, as when she is upon her back, perform it ourselves.- 

* Manual of Midwifery, 3d. Vol. 



UNAVOIDABLE HEMORRHAGE. 343 

the os externum, and prevents its passing out — from time to time 
some is permitted to escape by pressing the arm firmly against one 
side of the vagina, until a sufficient quantity has been evacuated ; the 
object of this gradual discharge of the waters is at once obvious ; it 
prevents the uterus from falling into a state of atony, by its being too 
suddenly deprived of them. The feet are now to be seized, and the 
body made to descend by drawing them down to the superior strait. 
We should now allow a little time for the uterus to contract ; when we 
are assured that it has done so, either by pains declaring themselves, by 
the child advancing farther into ihe pelvis without our exertion, or by 
the firm and hardened feel of the uterus through the parietes of the 
abdomen, we may most safely proceed to finish the delivery. 

109S. But should the woman be very much exhausted before we 
commence our operations, we should use additional caution in the de- 
livery — it must be very slowly performed, and we should have at 
each step of the progress, assurances if possible, that the uterus has 
not lost, or rather that it possesses sufficient contractility to render the 
completion of the operation eventually safe, if performed with due 
and necessary care. 

1099. We are advised by some, to pierce the placenta by the hand : 
but this should never be done ; especially as it is impossible to assign 
one single good reason for the practice, and there are several very 
strong ones against it. 1st. In attempting this, much important time 
is lost, as the flooding unabatedly, if not increasingly goes on. 2dly. 
In this attempt we are obliged to force against the membranes, so as 
to carry or urge the whole placentary mass towards the fundus of the 
uterus; by which means, the separation of it from the neck is in- 
creased, and consequently the flooding augmented. 3dly. When the 
hand has even penetrated the cavity of the uterus through the pla- 
centa, the hole which is made is no greater than itself; and conse- 
quently, much too small for the foetus to pass through, unless we force 
an enlargement ; and this can only be done by the child during its 
passage. 4thly. As the hole made by the body of the child is not 
sufficiently large for the arms and head to pass through at the same 
time, they will consequently be arrested, and if force be applied 
to overcome the resistance, it will almost always separate the whole 
of the placenta from its connexion with the uterus.* 5thly. That 
when this is done, it never fails to increase the discharge ; besides 
adding the bulk of the placenta to that of the arms and head of the 
child. 6thly. When the placenta is pierced, we augment the risk of 
child ; for in making the opening, we may destroy some of the large 
umbilical veins, and thus permit the child to die from hemorrhage. t+ 
While, on the contrary, the more the placenta is observed whole, the 

* Baudrlocque. + Baudclocquc. 

X Dr. Denman confesses, though he recommends the searching for an edge of the pfa- 
centa, and penetrating it, that in performing the latter "there is rather more danger 
of losing the child." — Midwifery, Francis^ ed. p. 434. 



344 UNAVOIDABLE HEMORRHAGE. 

less risk to the child, as we then disturb no vessels connected with 
its immediate safety. 7thly. By this method, we increase the chance 
of an atony of the uterus, as the discharge of the liquor amnii is not 
under due control. 8thly. That it is sometimes impossible to pene- 
trate the placenta, especially when its centre answers to the centre of 
the os uteri ; in this case much time is lost, that may be very impor- 
tant to the woman.* 

1100* It is a mistake to suppose we produce a greater separation 
of the placenta when we pass the hand between it and the uterus, 
than when we pierce the placenta. But if it were true, it would be 
no objection to the method I advocate, since both uterus and placenta 
are pretty firmly compressed by the arm in its passage to the fundus, 
and the bleeding by this means restrained ; and as this is the only ob- 
jection which is raised against the method recommended, I Shall con- 
sider it as completely answered by what is now said. 

1101. Should the placenta not be found entirely detached from the 
uterus after the birth of the child, we should give a little time for it 
to separate spontaneously ; and we must endeavour to promote this 
by friction upo'n the abdomen over the uterus, unless the flooding con- 
tinue to be violent ; it will then be proper to pass up the hand and 
separate it, for it may be the bulk of the placenta which keeps up the 
hemorrhage, by preventing the uterus from closing sufficiently upon 
the bleeding vessels. 

1102. Before I proceed farther, it may be well to inquire into Dr. 
Rigby's opinion concerning the nature of the uterine vessels, which I 
am content to call arteries. He says, " the uterine vessels differ very 
materially from arteries, and particularly in having no such power of 
contraction within themselves, their contraction and dilatation being 
absolutely dependent upon the state of the uterus. In the unimpreg- 
nated state they are so small as scarcely to be discovered ; but they* 
are well known to increase when the uterus receives the ovum, and 
to grow in exact proportion to its gravidity ; and when by the complete 
distention of it they have acquired their utmost magnitude, their dia- 
meters cannot be lessened until the womb, being again emptied, closes 
them by the contraction of its whole capacity, and restores them to 
their original size/' 

1103. There is no one circumstance in this history that would lead 
me to reject the idea, that a part of the uterine vessels are arteries, 
and for the following reasons: 1st., the spermatic and hypogastric 
arteries furnish the uterus w T ith these vessels; and it is well known that 
they increase in proportion as gestation advances ; consequently, ves- 
sels which all agree are arteries, enlarge, and in almost the same degree 
a& those within the substanee of the uterus, which are but continuations 
of them ; 2dly, no physical difference has ever been discovered be- 
tween them. , 

1104. These two circumstances I consider in themselves as con- 

* Dr. Rigby admits this, and declares he has ,c more than once found it." — P. 64. 



TTNA VOIDABLE HEMORRHAGE. 345 

elusive of the identity of the uterine, and the spermatic and hypogas- 
tric arteries. If not so, why should these vessels enlarge in proportion 
to each other ? And why should the spermatic and hypogastric arteries 
contract when delivery has taken place, without being dependent for 
this effect upon the "contraction of the uterus?" Now, let us see 
what would really present itself, were Dr. R's. opinion substantially 
true; he declares, in the unimpregnated state of the uterus, that these 
vessels " are so small as scarcely to be perceived."'' Now, how r 
should this happen if they possessed no contractile power within them- 
selves ? The mere contraction of the uterus could not alter their real 
capacity ; it could only change their form by strongly compressing 
them; therefore, if what he supposes were even true, they should con- 
stantly present to us the shape of flattened cylinders or puckered tubes ; 
but the contrary of all this appears when we cut into the substance of 
the uterus, for we then find that, though the vessels are- " so small as 
scarcely to be perceived," yet those we do see constantly present to 
us a circular form. 

1105. That they do not contract during pregnancy, or immediately 
after delivery, as closely as arteries in many other parts of the body 
do, I admit ; not because they do not possess contractility in an equal 
degree with these, but because they cannot exert it to the same extent, 
in consequence of their peculiar connexion with the general substance 
of the uterus — they are every way surrounded by, and connected with,, 
cellular membrane,* which will permit them to lessen themselves but 
to a certain degree, so long as the muscular fibres of the uterus remain 
in an uncontracted state, and for this plain reason, that the sum of their 
power or disposition to shut themselves up, is inferior to the power 
which keeps them in some measure upon the stretch. But that they 
do diminish in size to a certain degree, after being exposed, by a 
separation of a portion of the placenta during pregnancy, I have no 
doubt, as the cellular membrane by which they are surrounded, will, 
from its elasticity,! permit them to do so, and thus contribute to the 
suppression of hemorrhage. 

1106. We must regard the uterus during gestation, as in a state of 
coercion — every part and portion of it, sooner or later, is put upon 
the stretch ; consequently, the vessels entering into its substance must 

* I am rot wishing to be understood that there rs any thing peculiar in the uterine 
arteries being surrounded with cellular membrane: for this, we know, obtains where- 
ever there are arteries. I merely wish to insinuate an opinion, that thev have posi- 
tively less freedom than the arteries in the other parts of the body, by being more 
closely tied by their connecting media, and that, as I shall immediately say, for very 
important uses : and that they have relatively less, would appear evident, when we reflect 
on the immense increase they suffer during gestation; and though they may contract 
very considerably, yet it may be insufficient to stop their bleeding without the co-opera- 
ting contraction of the muscular fibres, for the reason I shall presently assign. Levrct 
makes the proportion of the unimpregnated uterus, to that of the impregnated, to be as- 
« leven and a half to one. Now, if the arteries augment (as it i* reasonable to suppose- 
they do,) in He same proportion, it will be seen how much their calibers must be re- 
duced before their contraction alone can stop hemorrhage. 

t Bichat, Anatom. Gen. 

30* 



346 UNAVOIDABLE HEMORRHAGE. 

enlarge with it, or put the cellular membrane, by which they are sur- 
rounded, upon the stretch ; but as there is a most important intention 
to be fulfilled by their enlargement, they are found to augment in a 
ratio correspondent to the distention of the uterus ; and they are not 
only made to yield in proportion to the increased demand for blood, 
but are also kept in that state by its constant influx, to supply the exi- 
gencies of the uterus in a state of gravidity. 

1107. This condition of the uterine vessels, then, has two causes 
contributing to the same end— namely, the unfolding and separating 
of the fibres constituting the proper substance of this organ, and the 
constantly increasing tide of blood which flows within it: the first, if 
it does not directly administer to, the enlargement of these vessels, will, 
to a certain- extent,, favour, it, by taking off that restraint which a state 
of contraction imposes upon them, and thus make them more certainly 
obedient to the impulses of the spermatics and hypogastrics — the vis 
a tergo, of these vessels, maybe considered as essentially contributing 
to their distention. Hence we can no longer recognise the almost 
imperceptible vessels of the unimpregnated, in the large canals, if we 
may so term them, in the advanced impregnated uterus. 

1108. Let us now suppose the supply to the uterine vessels to be 
cut off by any means whatever, and we make a section of the uterus 
near, or at the full time of gestation, and while yet occupied by the 
ovum — what will this section discover to us? One of two things, 
certainly — -either the vessels small and contracted, or still patulous 
and large. If in the first situation, Dr. Rigby's opinion of their nature 
is at once proved to be unfounded ; if in the latter, will it not confirm 
the notion I entertain, that they are kept in this situation by force, as 
above suggested, (1105?) if this be true, will not the same cause produce 
the same effect, when the uterus is emptied of its contents, but remains 
in a flaccid- and uncontracted state ? And will not the same conse- 
quences follow from the same cause in both instances, namely, a dis- 
charge of blood from the separation of the whole, or a part of the 
placenta ?* 

1109. If these statements be true, (and I sincerely believe them to 
be substantially correct,) it will follow, that the uterine arteries cannot 
contract sufficiently to stop hemorrhage, however eminently they may 
possess contractility, so long as the muscular fibres of the uterus are 
in an uncontracted state ; because their peculiar connexion with them 
will necessarily prevent it : and farther, I believe that this kind' of 
union highly contributes to the safety of the patient, after the ex- 
pulsion of the foetus, by enabling it, or, perhaps, I may say, inducing 

* I might also insist, that, should the uterine vessels be found large and patulous 
when the flaccid uterus was cut into, that it would not confirm Dr. R's. o inion, 
ahould the explanation just offered be admitted ; as it might be a reasonable conjecture 
to suppose that a cause capable of producing an atony of the muscular fibres of the 
uterus, might also be capable of rendering the uterine arteries passive ; and, conse- 
quently, this uncontracted condition of them would tend to prove that this was really the 
ease,, rather than that they had been endowed with the power of self-diminution. 



UNAVOIDABLE HEMORRHAGE. 347 

it to contract, to throw off the placenta, and prevent after hemor- 
rhage. 

1110. They perform this valuable end by lessening themselves, 
and obliging, in a certain degree, the muscular fibres to follow them; 
and this contraction proves an extensive and congenial stimulus, and 
is, for the most part, successfully exerted to this end. But, shoujd 
the muscular fibres of the uterus be indisposed, or unable, from the 
operation of any sufficient cause, to manifest a contractile power, he- 
morrhage must necessarily ensue. For the arterial extremities, which 
are exposed by the separation of the placenta, will and must remain 
open, not because they do not possess the faculty of contraction, but 
because it cannot be successfully exerted, for the reasons I have 
already assigned: therefore, that hemorrhage may cease, it is neces- 
sary to ensure the co-operation of the contractile fibres of the uterus ; 
and to make them obedient to this end, is the great aim of all our 
exertions. 

1111. From a review of the inquiry I have just made, it will be 
evident, that, as far as regards effects, there is but little difference be- 
tween Dr. Rigby and myself; but much, as regards structure and 
function. My object, in this attempt, is the removal of error, and not 
the expectation of any great practical advantage ; though I am per- 
suaded some benefit may be derived from these considerations, in the 
cure of hemorrhages of this kind. Upon the notion of the uncontrac- 
tility of the uterine arteries, Dr. R. condemns the use of that class of 
medicines called astringents ; but from the use of which I have fre- 
quently found great advantages, for the sugar of lead must be ad- 
mitted to be an astringent ; and in cases of flooding one of no 
common power. In the modus operandi of this medicine I may be 
mistaken, but I cannot be in its effects. There may be many other 
substances belonging to this class which may be equally, or even 
more efficacious upon trial; but we shall be deterred from employing 
them if we subscribe to the opinion of Dr. Rigby, that the uterine 
arteries "cannot contract of themselves." 

1112. The unavoidable, and hemorrhage after the birth of the 
child, are every way so interesting from their frequency, and danger, 
that we feel ourselves justified in offering every novel suggestion that 
presents itself to our reading, or to our observation. We do this for 
two reasons: first, to put our readers in possession of the views of 
oiher practitioners ; and, secondly, that we may have an opportunity 
To offer our remarks upon the opinions and suggestions of others, 
when such suLT'-r>stions do not appear to us either very practicable or 
very useful. With these objects in view, we shall relate what we 
have collected since the second edition of this work went to press, 
upon these important points. 



348 UNAVOIDABLE HEMORRHAGE. 



" A Case of Fatal Hemorrhage at the seventh Month of Utero-gestation, 
from the Placenta being placed over the Mouth of the Uterus, together 
with Remarks upon it y and several other Modes of treating Uterine 
Hemorrhage, 

1113. In this case it is stated that the patient lost. three pints of 
blood ; and became faint ; pulse ninety, and firm ; os uteri admitted 
the point of the finger, but nothing unusual could be discovered. 
Rest, cold, opium, and sulphuric acid, were prescribed. Profuse 
hemorrhage followed after some hours, probably eight, as the medi- 
cines were directed every four hours, and it was after the third dose 
a profuse hemorrhage followed. But before Dr. James, the narrator, 
could arrive, the woman was in a dying state. 

1114. Finding a large portion of the placenta in the vagina, and 
the os uteri fully dilated, he endeavoured to thrust his finger through 
the weakest edge of the placenta ; but failing in this attempt, he per- 
forated the centre of this mass, seized the feet of the child, and brought 
them into the vagina. A pain came on, but was not repeated ; and as 
hemorrhage followed, the child was extracted by mechanical means. 
Contraction of the uterus was solicited by the introduction of the 
hand ; pressure was made upon the abdominal aorta, to lessen the 
extent of the heart's circulation, but all to no purpose. " Life was 
gone."* 

1115. The history of this case gives rise to the following sugges- 
tions. First. It appears extraordinary that " nothing unusual could 
be discovered by the touch ;" or, in other words, that the placenta 
could not be detected upon examination, as the os uteri admitted the 
point of the finger ; especially as this mass must have been within reach, 
if a search had been made, as I have recommended, (1026,) by the 
introduction of the hand into the vagina instead of the finger alone. It 
may, therefore, be proper to insist again upon this being done, when- 
ever the degree of flooding renders it desirable to determine whether 
the hemorrhage be of the accidental or of the unavoidable kind; and 
this must be the case always when the discharge is very profuse. 

1116. Second. That a patient, who had lost " three pints of blood," 
and was " faint," should be trusted to the powers of opium, acids, 
&c; and the practitioner to feel so much confidence in them as to 
leave her for eight hours to their sole influence. In this case the pa- 
tient should have been narrowly watched, and the tampon should 
have been introduced, (1071.) 

1117. Third. It is evident from the statement that artificial delivery 
could have been performed, most probably a long time before it was, 
as upon the return of Dr. James, "a large portion of the placenta was 
found protruding through a fully dilated os uteri ; consequently, pre- 

* North Amer. Med. and Surg. Jour. No. 5, p. 203, from the Lond. Med. Rep. for 
September, 1826. 



UNAVOIDABLE HEMORRHAGE. 



349 



cious time was unnecessarily lost, and the danger of the patient aug- 
mented. 

1118. Fourth. That the efforts of the practitioner to procure the con- 
traction of the uterus should not have been confined to the introduc- 
tion of the hand alone. Brisk frictions should have been made upon 
the abdominal parietes ; and the ergot or sugar of lead, should have 
been given, before any attempt was made to deliver the child : nor 
should time have been lost in the attempt to pierce any portion or 
part of the placenta ; the hand should have been immediately passed 
between the uterus and the membranes ; the latter of which would 
have been easily broken, and this without the loss of a moment of 
time. 

1119. Fifth. No kind of reliance can be placed upon the attempt 
to diminish the "extent of the heart's circulation," by pressing the 
aorta ; for the tonic contraction of the uterus is altogether independ- 
ent of the general or local circulation of the blood. Besides, we do 
not think it possible to obliterate this enormous vessel by any means 
yet contrived ; the pressure of the hand is certainly incompetent to 
such an effect ; and if more rude means be employed, the parts inter- 
posing between the compressing power and spine may suffer severe- 
ly : the attempt, moreover, is but losing precious time. But let us 
suppose that the circulation in the aorta is temporarily suspended ; 
will this secure the patient against the renewal of the flooding when 
the pressure is removed ? Certainly it will not ; unless the uterus 
has spontaneously contracted : and if it be contracted, there can be 
no necessity for pressure upon the aorta. 

1120. It may, however, be said that we may gain time by this 
plan, and thus give a greater opportunity for the uterus to contract. 
This is vastly more specious than solid, for by directing our attention 
to the pressure upon the aorta, we prevent the employment of fric- 
tion upon the abdomen, which is much more important. Besides, 
the uterus is always found in such cases in one of two conditions ; 
namely, either entirely flaccid, or very partially contracted. If in the 
first, it must be included between the means employed for the ex- 
ternal pressure, and the spine ; consequently, it may be severely in- 
jured by a force that is equal to stopping the circulation in the aorta. 
If in the second, it will be found, that no force, which can be safely 
applied, will compress the aorta successfully through the abdominal 
and uterine parietes ; for it must be borne in mind, that the uterus, 
in either of the supposed cases, will be above the umbilicus ; and, 
consequently, will interfere with the attempt at pressure. 

1121. With the same object in view, Dr. James also recommends 
the use of tourniquets to the extremities: we fear this plan, like the 
one just noticed, will be found equally unavailing, even supposing 
the proper instruments to be at hand. Of a similar character is the 
proposal of Dr. Mojon to throw into the umbilical vein, after having 
expressed from it as much of the blood it contains as is practicable, 
as great a quantity of acidulated water as it will receive by means of 



350 UNAVOIDABLE HEMORRHAGE. 

a syringe. He declares this to have succeeded ; and requests others 
to repeat it. He says it required to be pushed with both force and 
promptitude. He thinks that the sensation of cold which the uterus 
perceives when cold liquor is injected, favourably promotes the sepa- 
ration of the placenta.* 

1122. The notice we have of this new method of relieving the 
placenta in cases of hemorrhage is very imperfect. We are not in- 
formed of the condition of the uterus previously to the injection of 
the acidulated water ; whether it was in a state of inertia ; or whether 
it was owing to an unusual obstinacy of adhesion : or whether any at- 
tempt had been previously made to arrest the discharge, and it had 
failed. For we must declare, that merely to save the introduction of 
the hand, as he avows, is by no means sufficient to induce a well-in- 
structed accoucheur to depart from a method which has been suc- 
cessful for centuries, and which, in general, is not attended by either 
difficulty or danger. Besides it may well be questioned, whether the 
liquid employed by Dr. Mojon had any agency in relieving the pla- 
centa from its adhesion ; as we well know that this mass is often very 
suddenly thrown off without any interference. Moreover, it can only 
be useful in such cases, (if it ever be useful,) as are attended with 
a partial separation of the placental a condition we are bold to say, 
neither Dr. Mojon nor any other man, can determine with certainty 
without the introduction of the hand, if it be essential that this point 
shall be determined ; and if this be necessary, as we believe it would 
be, the hand had much better perform its duty, while it has posses- 
sion of the uterine cavity, than to be withdrawn to aid in the injec- 
tion of a cold acidulated water. 

1123. Again ; all the pains just noticed, necessarily suppose, that 
all the mechanical agents necessary to fulfil the indications, (and we 
see these are sufficiently varied,) are at hand, and can be called into 
requisition sur le champ ; for these cases admit of no delay when ex- 
treme ; and it is only when extreme, that they are proposed, or can 
be proper. Were these methods to be adopted into general practice, 
it would require constantly a serious load of metal for the poor ac- 
coucheur to carry into the bed-room of his patient, \ or run the risk of 
losing his patient, if these are the only means to be relied on. 

1124. We should place also under the same ban, the lately re- 
newed expedient of " transfusion." We do not hesitate to credit the 
accounts of women not dying when this scheme has been resorted 

* Revue Medicale, &c, for June, 1826, p. 502. 

t The reason of this is at once obvious, for should the placenta be separated alto- 
gether, the liquid cannot be so applied to the uterine surface, as to niake this organ 
perceive the impression of cold, and induee it to contract. Besides, it seems to be ad- 
mitted, that it is by the uterus perceiving a sensation of cold, that it is induced to con- 
tract. Now, it is well known that this can be accomplished in a much more simple 
plan ; namely by applying cold water or ice to the abdomen, or introducing the latter 
into the cavity of the organ. 

X Dr. Slop's bag would have been very much too small, ample as it was, for so much 
ingenious machinery. 



UNAVOIDABLE HEMORRHAGE. 351 

to ; but we very much doubt whether the patient would have died, 
had it been withheld. We believe this principally on the following 
grounds: — first, because women bear excessive losses of blood with- 
out death following ; secondly, because the quantity of blood trans- 
mitted to the alien veins does not appear sufficient to prevent death, 
since but a very few ounces have been declared to answer ; thirdly, 
because the additional quantity of blood, though it increases by so 
much the stock of the patient, it does not necessarily or contingently 
promote the tonic contraction of the uterus, without which, all " ap- 
pliances and means to boot," will be found unavailing; fourthly, 
because we have never yet met with a case in which the dormant 
powers of the uterus could not be roused into successful action, if 
means were timely employed, were of a suitable kind, and were 
properly applied. All these plans appear to us to savour too much 
of the improvements of Sir. Abel Handy.* 

1125. The cases related by Mr. Waller, are as strongly marked as 
any, perhaps, that have met the public eye ; yet to us they are by no 
means conclusive. We can find in Rigby, Leroux, La Motte, Mau- 
riceau, &c, &c, cases equally formidable, where recoveries took place 
without this means. And if we be permitted to enforce the above 
opinion by observations of our own, we could certainly relate a num- 
ber of cases, where the subjects of them were reduced to as great 
extremity as those furnished by Mr. Waller: we shall, however, only 
refer to the one related in a subsequent part of this article ; though 
many equally formidable,, and equally successful, could be fur- 
nished. 

1126. There appears to be excited, at the present time, a passion 
for novelty in the treatment of uterine hemorrhage ; but no remedy or 
means that has hitherto reached our knowledge, appears to have any 
decided efficacy in themselves, in arresting this discharge. Both the- 
rapeutical and mechanical agents are anxiously sought after ; and 
each inventor of a new mode of fulfilling an old, and never to be 
deserted principle, vaunts his supposed improvement with a confi- 
dence that almost bids defiance to skepticism, until trial is made of its 
boasted powers; it is then found to have no superiority over the re- 
medial agents already known, and heretofore relied upon. In all 
these attempts it appears to be forgotten, that the only indication in 
a threatening hemorrhage after the delivery of the child, is to procure 
the tonic contraction of the uterus ; yet some of the means had re- 
course to, are but ill-calculated for this end. Of this kind is " trans- 

* Handy, Jr., demands, after Sir Abel has set the house on fire by his experi- 
ments, •' What is to be done? Where's your famous preparation for extinfruishinjr 
flames r y ° 

44 Sir AbeL It is not mixed.'" 

11 Handy Jr. Where's your fire escape?" 

"Sir Abel. It is not fixed." 

"Handy Jr. Where's your fire engine?" 

44 Sir Abel. 4 Tis on the road."— {Speed the Plough.) 



352 



UNAVOIDABLE HEMORRHAGE. 



fusion ;" " the filling of the uterus with rags ;" " the compression of 
the aorta;" injecting the umbilical vein," &c, &c. And the 
therapeutical means, such as the introduction of vinegar, or the 
acid of lemons, have no other power perhaps upon the flaccid 
uterus than as a kind of vehicle to the mechanical agents, if we may 
so express it ; and a variety of these can unquestionably be employed 
with at least equal success without their assistance. Yet. we hold 
it proper to lay before the inexperienced practitioner all the means 
which have of late challenged the attention of the medical public. 
Therefore, with this impression upon us, we shall relate several other 
schemes, on which the changes have been rung with much compla- 
cency in our various periodical journals. 

1127. Messrs. Gorat, Evrat, &c, propose the immediate applica- 
tion of the citric acid to the internal surface of the uterus, with a view 
to arrest hemorrhage *after delivery. They describe this method in the 
following terms : they strip a lemon of its skin, and having cut one 
end of it, they carry it into the uterus, and then express the juice on 
the sides of the cavity. They allow the decorticated lemon to remain, 
until the irritation produced by the juice, and this foreign body, ex- 
cite the uterus to contraction, which, constringing the tissue of that 
organ, stops the hemorrhage, and the lemon is expelled with the co- 
agulum formed about it.* 

1128. This is one of the late improvements in the treatment of 
this formidable complaint, and to which we have just alluded. It 
will be, in most instances, in this country at least, in the same pre- 
dicament as several of the means we have already noticed — rarely at 
hand when required. It will also be seen, that from the mode of its 
application it acts but as a mechanical stimulant upon the uterus ; 
and w T e-are disposed to believe in no manner superior, or more cer- 
tain than the naked hand, so very many years recommended. For 
in a hemorrhage that would require manual interference, we are of 
the opinion that the small quantity of acid which could be expressed 
within the uterus, would be so effectually and suddenly diluted by in- 
fluent blood, as to render its powers altogether nugatory. Now, we 
know from experience, that the very presence of a foreign body 
within the cavity of the uterus, and this passed, perhaps, even some- 
what rudely over its surface, will cause it to contract, and thus arrest 
the discharge ; and this mechanical influence has been acknowledged 
for more than a century. For we perfectly disclaim all effects from 
the acid; and for the reason just stated f and we cannot but regard 

* Anderson's Quarterly Journal, Vol. II. No. VI. p. 298. Revue Medicale &e. &c. 
&c. 

t In addition to what we have urged above, against the agency of (he acid produ- 
cing any effect from its own properties, it may be added, that in such hemorrhages as 
occur before the entire separation of the placenia, the whole, or very near the whole, 
of the internal surface of the uterus, is still lined by the membranes ; and, consequently, 
the acid cannot be placed in contact with the uterine fibre : therefore, if any effect 
follow the introduction of the lemon under such circumstances, it must proceed fiom 
its mechanical irritation, aided by that of the hand. Besides, the author of this me- 



UNAVOIDABLE HEMORRHAGE. 353 

the suggestion of M. Gorat, &c. as one of those determined attempts 
at novelty which a little subsequent experience will cure. 

1129. A woman aged thirty-two, was taken in labour with her 
first child, on the 12th of February, 1825. The pains soon ceased, 
and on the 15th. M. Bedel, physician at Schirmack, was consulted, 
who speedily delivered her with forceps, of a dead child. The 
hemorrhage was so considerable as to render the immediate removal 
of the placenta necessary ; but the uterus did not contract, and the 
bleeding continued, together with tremblings, syncope, cpld sweats, 
&c. Irritation on the internal surface of the uterus, cold water to the 
abdomen, injections into the uterus of cold water and vinegar, were 
unavailing. 

1130. Plucrcrirjcr the vagina and also the uterus, were now resorted 
to, as the only remaining means of safety. The uterus was filled 
with pieces of rags, for fear the patient could not sustain the loss of 
blood necessary to fill the cavity ; while a methodic compression was 
at the same time, made upon the abdomen. The hemorrhage was 
immediately arrested, and soon after reaction ensued. 

1131. On the 16th, Mr. Bedel removed the plugs from the uterus 
cautiously and successively :* and had the pleasure to find the ute- 
rus to contract regularly after each removal. The lochial discharge 
continued : but there was no secretion of milk. The patient reco- 
vered slowly, f 

1132. This is another instance of attempting to arrest an alarm- 
ing uterine hemorrhage in a new way ; but it more strongly recom- 
mends itself to us than some others, from its having succeeded in 
the instance in which it was tried, and from the simplicity of its 
plan, and the certainty of the materials to operate with being almost 
always at hand. But we cannot help feeling surprised, 1 that we 
do not find an instance, among those we have recorded, in which 
well-directed and properly continued frictions over the region of the 
uterus have been instituted ; a means, which has ever, in our hands, 
proved certain in restoring the lost energy of the uterus. Nor is 
there any case related, within our knowledge, out of this country, in 
which the acetate of lead has been given in proper doses ; nor in 
which the ergot had been resorted to, until very lately, though the 

thod of treating uterine hemorrhage lays stress upon the sudden ejection of the citric 
acid by the pressure of the hand ; but Chaussier tells us, in pressing a lemon, cut as 
directed, and squeezed very tightly, it will not throw out its liquors in streams as stated 
by the inventor. At all events, it is no improvement upon the sponge and strong 
vinegar, long since recommended for the same purpose. 

* We believe a great error has often been committed in using the tampon — we think 
fro n what gentlemen say of their treatment, that they have literally plugged the ute- 
rus, and in this way we would account for its often failing, and certainly after the ex- 
hausting discharges the uterus would be left in almost a flaccid state. Then to intro- 
duce a tampon into ita month, I think would be worse than doing nothing. For in 
this case the relaxed uterus would be quickly filled with blood, and that in a quantity 
that would sink the woman beyond recovery. 

t Bulletin Universal, for Januan* 182G, from the Gazette de Sante, for December, 
1825. 

31 



354 UNAVOIDABLE HEMORRHAGE. 

success of these drugs in uterine hemorrhage has been frequently 
proclaimed in the periodical journals of this country for at least the 
last eight years. 

1133. Nor are we less surprised at the misapprehension, which 
almost constantly seems to prevail, as regards the use of the tampon 
in the cases under consideration ; for it is to the ill-timed application 
of this remedy, that we must attach its want of success. Leroux 
does not propose this plan as certain of success in floodings which 
follow the expulsion of the placenta ; though he declares he has suc- 
ceeded sometimes with it in such cases. Its great value is in flood- 
ings before impregnation ; before the uterus is emptied, when it is 
impregnated ; and when this organ will contract when labour is ter- 
minated. 

1134. In entering upon this part of our subject, it will be impor- 
tant to the consideration, that we say a few words upon the changes 
effected in the uterus itself, by the delivery of the child, and the ex- 
pulsion of the placenta. 

1135. I regard the uterus as a hollow muscle ; and like the other 
hollow muscles, has no separate or independent antagonizing form ; 
but has, like them, a compensating one, arising from its own organi- 
zation or structure;* and also like all the muscles of this kind, when 
not distended by some distracting force, will contract by virtue of 
some power of its own, and upon the healthy disposition of this kind 
in the uterus does the welfare of the woman depend, in every in- 
stance of child-birth or abortion. 

1136. I shall not stop to inquire, as its consideration is not imme- 
diately involved in the present investigation, whether this is a legiti- 
mate muscular contraction, or the exertion of that power, common to 
many organic, as well as inorganic substances, termed elasticity. My 
own opinion, however, is decidedly made up, that the efforts the 
uterus makes to expel its contents, and to close itself after it has per- 
formed this office, is by virtue of a genuine muscular contraction. 

1137. In the performances of these offices, two distinct powers are 

* I say, that the uterus has, like the heart, and perhaps all other hollow muscles, an 
antagonizing power within itself, and this by its own organization. I shall attempt to 
prove this, by stating that in consequence of that contraction, which we call the alter- 
nate contraction of the uterus, having taken place, a considerable portion of the blood 
which at that moment occupied the uterus, is driven quaqua versum into the general 
system ; a facility for which is derived from the frequent anastomoses of the arteries 
and veins, and by the latter not having valves. This is proved by the diminished 
thickness of the uterine parieties, and by the whole surface of this organ becoming 
paler at the moment of contraction. This state of things continues until this effort 
has ceased — so soon as this happens, (which may be longer or shorter, according to 
the power which governs the contraction, and the state perhaps of the muscular fibres 
of the uterus itself,) the vessels which had just been deprived of a portion of their con- 
tents by the contraction, will at the moment of relaxation be but imperfectly filled, and 
even a genuine vacuum may be induced ; but so soon as the restraint imposed upon 
the whole of the uterine vessels by this contraction is taken off, the blood will instantly 
rush into them, to restore the disturbed equilibrium, and thus again distend these ves- 
sels; which distention will prove a stimulus to the uterine fibres, and thus induce a 
new contraction : and in this way would I account for the alternate pains of labour. 



UNAVOIDABLE HEMORRHAGE. 355 

concerned. One shows itself by a constant disposition to lessen the 
cavity of the uterus, whenever it may be put upon the stretch: or at 
least whenever the cause is removed, that placed it in that condition. 
The other declares itself by alternate contraction, which is perhaps, 
only an exalted degree of the same power when urged by stimuli as 
in child-birth, abortion, or from any other circumstance which may 
require its interference, to expel a foreign body from its cavity. 

113S. The first of the powers just noticed, has been termed " tonic 
contraction ;" and the second M spasmodic contraction," from its 
being usually, though not necessarily, attended with pain. This 
latter it must be remembered cannot take place without the former 
having preceded it : though the former can happen without the 
latter.* (251, 252.) 

1139. Now, the economy of the uterus, in its healthy condition is 
such, that it immediately exerts its tonic force to close upon, and to 
accommodate itself to the exact size and shape of such contents — thus, 
as soon as the iiquor amnii is discharged, the uterus instantly dimi- 
nishes its size, by virtue of this tonic power, and this in the exact, 
proportion to the quantity of water displaced. So plastic is this 
power, that it makes the parietes of the uterus assume the inequalities 
presented by the surface of the child ; and, when the child is deli- 
vered, it reduces itself so much as to compress the placenta, and force 
it from its attachment ; and eventually expels it from its cavity. When 
this is achieved, it goes on reducing itself, until it interrupts in a great 
measure the supply of blood from the spermatics and hypogastrics ; 
closes almost completely the mouths of the vessels exposed by a sepa- 
ration of the placenta, and thus prevents any inordinate flow of blood. 

1140. From this it appears, that the safety of the woman depends 
almost entirely upon the healthy exercise of the power just termed the 
" tonic contraction;" and, on the contrary, that the risk she may run 
in giving birth to her child, is in exact proportion to the diminished 
force of this power ; of course, the preventing and stopping of flood- 
ings, will depend upon recalling it when absent, or augmenting upon 
it when deficient. 

1141. The tonic power of the uterus may be feeble, or altogether 
wanting — it may be lost in every portion of the uterus, or only in a 
part ; thus, the fundus may possess it, and it may be absent from the 
body and neck ; this may give rise to the diversion of the uterus. 
The fundus and neck may be deprived of it, while the body may 
enjoy it; this may occasion the hour-glass contraction. The body 
and fundus may be exhausted of it, while the neck retains it ; — this 
may produce the concealed hemorrhage. The body and fundus may 
be firmly contracted, while the neck of the uterus may be flaccid— 
this may occasion flooding, if the placenta has been attacked in that 
vicinity. 

* Fee Essay on the Means of lessening Pain in certain Cases of Labour, «Scc., by 
the author. 



356 



HEMORRHAGE, BEFORE 



Sect. VI. — 6. Causes of Uterine Inertia. 

1142. The remote causes of uterine inertia are said by Leroux 
and others to be, 1st. A general morbid condition of the body, as 
tendency to scurvy, &c. 2d. Long illness. 3d. A depraved con- 
dition of the circulating mass. 4th. Unusual laxity of fibre, as in 
leucophlegmatic habits, &c. 5th. Over-distention, from an excess of 
liquor amnii. 6th. Strong emotions or passions of the mind. 7th. 
A long protracted labour. 8th. A previous hemorrhage. 9th. Le- 
sions in the proper substance of the uterus itself. 

1143. But the condition of the tonic power is far from being al- 
ways regulated by the contingent situation of the general system; we 
cannot infer its absence from the debilitated state of the body at large ; 
nor can we calculate upon its presence with certainty, because every 
other function is carried on vigorously. This is a fact well known to 
every practical accoucheur, and should teach us this highly important 
caution — to act as if this power were, or easily might be expended 
and to consider no woman safe from the casualty of its exhaustion, 
until we are assured to the contrary by a careful examination. 

1144. Fortunately for the patient, as well as for the practitioner, 
this power, when weakened, nay, even to excess, may almost always 
be recalled by proper means, and is almost certainly obedient to the 
judicious use of appropriate stimuli ; but, upon the time and manner 
of this application, much will be shown presently. 



Sect. VII. — 7. Of Hemorrhage before the Placenta is expelled. 

1145. We are now to consider hemorrhage as it may occur before 
the placenta is expelled. It must be recollected that a flooding can- 
not happen but when the placenta is in part, or wholly separated from 
the uterus ; and that this separation has been effected in the cases we 
are now to speak of, by uterine contraction, unless a sufficiently 
powerful mechanical cause had been previously offered. For, so 
long as the placenta preserves its continuity entire with the uterus, no 
flooding can ensue, should this viscus be even in a state of complete 
atony or exhaustion.* 

* Unless some mechanical violence has been done to the uterus, either from external 
impression, or from some incautious manoeuvre performed within \U cavity, as in the 
act of turning, or the injudicious use of instruments, the placenta will preserve iis con- 
nexion with the uterus until disturbed by uterine contractions, and, consequently, there 
will be an exemption from flooding 1 until this takes place; but this connexion may be 
destroyed in a moment by the causes just stated, and a hemorrhage as quickly follow. 

Since writing the above note an interesting case has occurred, which completely 

proves my position. Mrs. , on the 23d of march, 1823, was taken, at her full 

period, with slight pains, and the other marks of approaching labour. Soon after these 
had manifested themselves, she was seized with violent vomiting, and considerable 
hemorrhage ; there was an almost constant effort in the uterus to throw off its contents, 
together with an occasional increase of pain. I was now sent for, and found the patient 



THE PLACENTA IS EXPELLED. 357 

1146. As there is considerable variety in these cases, it will be 
well, for the sake of perspicuity, to consider them under the following 
heads. 

a. 1st. Where there is a partial separation of the placenta, but the 
uterus enjoying some tonic power. 

b. 2d. Where there is a partial separation, but the uterus possessing 
very little or no tonic power. 

c. 3d. Where there is a partial separation of the placenta, while 
the remaining portion is too adherent, and the uterus contracts 
but feebly. 

d. 4th. Where every thing is as at 3d, except that the uterus enjoys 
its full power. 

€. 5th. Where there is an entire or partial separation, but the uterus 

in a state of exhaustion or syncope. 
f. 6th. Where there is either a partial or complete separation of 

the placenta, and where the body and fundus are in a state of 

inertia, while the neck enjoys its tonic power. 



a. I. — Where there is a partial Separation of the Placenta, but the 
Uterus enjoying some tonic Power. 

1147. In this case the last efforts of the uterus to expel the child 
may have occasioned a partial separation of the placenta, and of 
course, there will be a greater or less discharge of blood : 1st. As the 
exposed surface may be large or small. 2d. As the contractile power 
c»f this organ may be more or less perfect. 3d. As the circulation of 
the blood may be more or less hurried. 

1148. In almost every instance after the birth of the child, w r e find 
a quantity of blood issue from the vagina ; but the young practitioner 
must not look upon this as a hemorrhage, unless it continue some 

as above stated. The vomiting returned from time to time ; and whenever it did so, 
there was an increase of the hemorrhage; and this also occurred when the alternate 
pains were on, which gave rise to a suspicion that it was a placental presentation. I 
ordered the patient to her bed ; and, upon examination, the membranes were found pro- 
truding, and the child rapidly advancing. I ruptured the membranes immediately, 
and the hemorrhage was instantly suspended: in a few minutes more the child was 
expelled, but still-born. The navel string was cut, but not a drop of blood issued from 
either portion of it. Every effort was unavailingly made to resuscitate the child. 
The placenta was found loose in the vagina, and, upon examining its surface, it was 
found covered over its whole extent with a thin black coagulum, an evidence it had 
been entirely separated, and the child made to perish in consequence. The uterus ap- 
peared to contract well, and every thing was promising for an hour : at the expiration 
of this time, the uterus relaxed, and a profuse discharge instantly took place. When 
I arrived, (for I had taken my leav< ,) the patient was very faint, extremely sick at the 
stomach, and very restless, which necessarily augmented the discharge. I immediately 
commenced pretty brisk frictions upon the abdomen — the uterus soon contracted, and 
did not again relax. Two grains of opium were ordered every two hours, until the 
patient should become tranquil. On the following morning she was found much re. 
cruited, and had in unpleasant svmptom afterwards. 

31* 



358 HEMORRHAGE, BEFORE 

time, and has an evident effect upon the pulse.* In this case, he is 
immediately to attempt to arrest it, by soliciting an increased contrac- 
tion of the uterus, by pretty briskly passing his hand over the region 
of the uterus, and from time to time attempting, as it were, to grasp 
the uterus by closing his fingers upon it. 

1149. By proceeding in this manner, he will almost instantly find 
the uterus harden under his hand ; a coagulum of a greater or less 
size will escape from the os externum ; a slight pain may come on, 
and the placenta may be thrown down into the vagina. When this 
contraction takes place, as it almost always does when the woman 
has not been too much exhausted either by a long protracted labour, 
or by disease, the discharge of blood is quickly put a stop to ; the 
uterus diminishes much in size, and retires almost within the pelvic 
cavity, while the placenta is entirely detached from the uterus, or it 
may even be expelled from the vagina. This is, perhaps, the most 
simple case of flooding that can occur, and I believe it never requires 
any other management than frictions upon the abdomen ; its termi- 
nation may not always be so sudden as I have now stated, but it is 
sure to take place in a very short time, and as fortunately as I have 
described it to do. 



b. II. — ■ Where there is a partial Separation, but the Uterus possesses very 
little or no tonic Power. 

1150. In this case, the same cause may produce the same effects 
as in I. ; but the uterus may be in a very different condition : here 
there will not only be a discharge of blood in proportion to the surface 
exposed by the separation of the placenta and the state of the circula- 
tion, but also a continuance of it, commensurate with the antonic 
condition of the uterus. 

1151. This state may continue for a longer or a shorter time, ac- 
cording to the force of the remote cause which induced the atonic 
state of tHe uterus, or as it may be of easy or of difficult removal. 

1152. In this, like every other case of flooding at this period, we 
should endeavour as quickly as possible, 1st. To remove the cause 
which induced the atonic state of the uterus, wherever it is evident 
and practicable. 2d. To excite, as soon as may be, uterine con- 
traction. It will be readily perceived, that we cannot control some 
of the remote causes of inertia just enumerated, and, therefore, our 
chief attention should be directed to the fulfilment of the second ; and 
this should be immediately attempted by frictions upon the abdomen, 

* Some women will bear a much greater loss of blood than others ; and therefore, 
we are to decide upon the propriety of interference, from the effect which this loss has 
upon the system, rather than from the quantity which has been expended. If we do 
not attendto this rule, we shall interfere unnecessarily where the powers of the system 
are every way competent to the exigencies ; and in other cases we may delay assistance 
so long as to render it unavailing. 



THE PLACENTA IS EXPELLED. 359 

as above directed. On frictions I have the greatest reliance ; and I 
never fail to employ them, with a view to promote contraction, whether 
there be hemorrhage or not, provided the uterine globe be not felt firm 
upon the application of the hand to the abdomen immediately after 
the child is removed from the mother ; and when there is a flooding, 
I chiefly rely upon them, to restore the energy of the uterus ; and in 
this I never have been disappointed — its influence is as prompt as it 
is efficacious ; indeed, I consider frictions as indispensable, let what- 
ever other means be employed. 

1153. I have never had the misfortune to meet with a uterus that 
was altogether insensible to this mechanical stimulus; nor to lose a 
patient from the immediate loss of blood ; and I can with great truth 
affirm, that this simple plan has constantly appeared to me to be the 
chief agent in arresting the most formidable floodings of the kind I am 
now considering. The external face of the uterus, when acted upon 
by the hand through the abdominal parietes, appears to me to be 
equally sensible to stimuli of the mechanical kind, as the internal 
surface ; and it certainly offers facilities and advantages that the cavity 
does not : — 1st. It is always accessible to be acted upon ; 2d. No 
risk is run by very freely stimulating it with the extremities of the 
fingers ; 3d. It excites very little, or no pain, if judiciously managed ; 
4th. No fear is to be apprehended of increasing the discharge, which 
is not always die case when the hand is employed within the uterine 
cavity ; 5th. No danger of inducing inflammation or other injury, as 
may happen by the introduction of the hand. 

1154. The attempt to arrest hemorrhage, by reviving the powers 
of the uterus, is not new ; it was long since recommended by a Mons. 
Dasse,* an accoucheur of Paris, whose method, though I do not 
exactly follow it, I will give in his own words. " II ne faut que 
porter les deux mains sur la region hypogastrique, et comprimer 
mollement le corps de la matrice par un mouvementtantot circulatire, 
tantot de droite a gauche, de gauche a drqite, de haut en bas et de bas 
en haut. Tons ces differens mouvemenssont absolument necessaires, 
a cause des differens plans de fibres que se'entrecroisent et forment 
une espece de reseau." 

1155. I have just observed, that I do not exactly follow his method ; 
though the effect is precisely the same. One hand is all that is ne- 
cessary, or that can be conveniently employed ; and if this be indus- 
triously and properly used, I am persuaded that it will rarely fail. I 
must, however, in justice to myself, declare, I was in the habit of 
employing this method long before I was aware it had been previously 
recommended by M. Dasse. 

1156. When we have adopted this method, we are to take care we 
do not abandon it too sotfn ; for it is not sufficient that we procure the 
contraction of the uterus ; we must maintain it in this condition for 
some time, and this by the continuance of the friction. And I would 

* Journal dcs Savan's d'Aout, 1792, p. 474. 



360 HEMORRHAGE, BEFORE 

at this time caution the inexperienced practitioner, against a very- 
natural cause of alarm ; when almost at the instant he feels the uterus 
hardening and diminishing under his hand, he hears very distinctly a 
considerable discharge of coagula and fluid pass from the vagina ; 
and at the same moment he finds the uterus retiring, as it were, from 
under his hand. 

1157. This discharge is but the effect of the contraction induced by 
his manoeuvres upon the external surface of the uterus, and must be 
regarded as a favourable omen, as it assures us that the uterus is 
about to regain its powers. Perseverance is now all-important : the 
frictions are to be continued until he has sufficient evidence of the 
permanency of the contraction, by noting that the uterus no longer 
relaxes itself, as it did most probably at the commencement of his 
operations. 

1158. Should this plan, however, not succeed in detaching the 
placenta, and stopping the flooding, we are, secondly, to deliver the 
placenta by the introduction of the hand within the cavity of the 
uterus, as this mass must now be considered as the cause of the con- 
tinuance of the hemorrhage, by preventing the uterus from contract- 
ing sufficiently to shut up the mouths of the bleeding vessels. It 
will be found either partially or entirely detached. If in the first 
condition, we insinuate carefully the fingers behind the loose portion 
of the placenta, and gently separate the adhering part: we then grasp 
the mass in the hand and rotate it several times against the internal 
face of the uterus, with a view of more certainly procuring subse- 
quent contraction ; nor must the hand be withdrawn until this is per- 
ceived. Should the uterus, however, be found to contract firmly 
upon the hand, immediately after it has effected the separation 
of the placenta, it may be gradually, but never suddenly with- 
drawn.* 

1159. If the placenta be found detached from the uterus, it must 
be withdrawn ; but the same precautions should first be practised. 
We must not, however, consider the patient free from all risk, be- 
cause the placenta is extracted ; we should examine the condition of 
the uterus, by again placing the hand upon the abdomen : if it be 
well contracted, it will be found hard and about to sink within the 
pelvic cavity, which will give us strong grounds to believe that the 
woman is about to do well ; but if, on the contrary, the uterus is 
found large and not very firm, we have every reason to fear there 
will be a renewal of the flooding, and the frictions must again be had 
recourse to. 

1160. It must be confessed, however, that the young practitioner 
may not be able, without some farther directions, to detect the flac- 
cid condition of the uterus, though he may be very able to perceive 
a contracted one — I shall, therefore, state, that when the uterus is 

* If the uterus regain its wonted powers, the hand, with the placentary mass, will 
be expelled almost immediately from its cavity ; but even when this effect is perceived,, 
the hand should not be permitted to leave it too suddenly. 



THE PLACENTA IS EXPELLED. 361 

not contracted, the whole abdomen appears equally soft and pliant 
— if the extremities of the fingers be pressed backward from the 
pubes, no hard unyielding tumour is perceived ; and if be inquire 
into the state of the discharges from the vagina, he will find them, if 
not profuse, more abundant, than they should be — when all these 
circumstances combine, he may be certain the uterus is in a state of 
inertia ; and he will soon be convinced of this, after he has com- 
menced the friction upon the abdomen, (and which should be imme- 
diately done,) by finding it to harden, sometimes suddenly, at others 
gradually, under his hand, and presently retire, when well-condi- 
tioned, into the pelvis, or at least the fundus will be found below the 
umbilicus. 

1161. In all cases of severe flooding of this kind, I am in the 
habit of directing the nurse, or any intelligent woman, to renew 
these frictions from time to time for an hour or two after my de- 
parture, and more especially should there be a return of discharge, 
that no evil may arise until I can again attend to the patient. 

1162. 3d. I think it best to call in every aid in such cases that 
may be at command. The ergot, in twenty-grain doses, must be 
given immediately, and repeated in fifteen minutes if necessary. 
Late experience seems to declare it preferable to the acetate of lead, 
and I now employ it in its stead. 

1163. It is not unusual, where the woman has sustained consider- 
able loss of blood, for the stomach to become much deranged. 
Vomiting or great nausea, is almost always an attendant upon it ; 
and when either takes place, it becomes very fatiguing and distress- 
ing to the patient. If she vomit, the exertion is so severe as some- 
times to exhaust her almost to syncope ; and during this act, there is 
almost always a greater or less discharge of blood, which at this 
moment can be but ill spared — if it be sickness of stomach, it renders 
the patient so wretched, that she cannot rest quiet for a moment 
together in one position ; she therefore tosses about from place to 
place, until she is almost spent — I dread this latter condition more 
than an occasional effort to vomit, as it seems to interrupt the tonic 
contraction of the uterus, by the influence which nausea is wont to 
exert over all muscular power, as well as to induce immediate ex- 
haustion, by producing unceasing jactitation. Nothing tranquillizes 
the stomach under these circumstances, so far as I have observed, 
like opium, in the solid form. A newly prepared pill of two grains 
of the opium, with a very small portion of soap, to facilitate its solu- 
tion in the stomach, should be given every hour or two, until the 
vomiting ceases, or the stomach becomes reconciled. I have found 
a sinapism over the region of the stomach of great service, and should 
be resorted to, if necessary. 

1164. Should the discharge be too abundant after the expulsion of 
the placenta, though not amounting to a flooding, it should be mode- 
rated by the use of the frictions and the ergot. 



462 HEMORRHAGE, BEFORE 



e. III. — Where there is a partial Separation of the Placenta, while the 
remaining Portion is too adherent, and the Uterus contracts but 
feebly. 



1165. A flooding may be excessive under the circumstances men- 
tioned in this variety, and considerable time may be lost in vainly 
soliciting the extrusion of the placenta by frictions upon the abdomen, 
and efforts exercised upon the cord,* before it is suspected that this 
mass may be too adherent — it is fortunately but of rare occurrence, 
but its management on that account should be the better defined. 

1166. We cannot know with certainty, if this complication exist, 
until the hand be pressed into the uterus, and a proper examination 
made of the condition of the placenta ; for this case, as far as regards 
common symptoms, resembles almost every variety of retained pla- 
centa, and nothing but a strict search can justify its being pronounced 
a case of adherent placenta. This excuse, I am aware, is frequently 
employed to justify the introduction of the hand into the uterus, to 
bring away the after-birth by force, when it required but a little more 
time, or a little more address, to be delivered by the natural agents. 
We frequently hear young practitioners boast of the difficulties they 
have encountered in delivering the placenta ; but we rarely meet with 
an experienced one, who complains of the same thing. 

1167. In this country, I believe that the adherent placenta is of very 
rare occurrence; while, in Great Britain, or rather perhaps, London, 
it is comparatively frequent, agreeably to the testimony of Dr. Rams- 
botham.f 

1168. There is something remarkable in the occurrence of this con- 
dition of the placenta, for which we do not pretend to account. For 
we cannot well suppose, that a practitioner of so much experience as 
Dr. Ramsbotham, and one who seems to possess so much talent for 
observation, can have mistaken the nature of the cases he describes, 
as " too adherent placentas." In this country, at least so far as my 
own experience will justify the remark, this diseased condition of the 
placenta is extremely rare ; not having met with more than two or 
three cases in more than forty years. It would also appear to be of 
very rare occurrence in some part of Germany, as a Dr. Seiter declares 
he had not met with a single case, " d'adherence anormale entre le 

* Whenever an attempt is made to deliver the placenta by force being applied to the 
cord, great care should be taken that it be not so great as to separate the funis from this 
mass ; for if this occur, it would be most probably necessary to introduce the hand, 
which sometimes creates to the young practitioner a good deal of embarrassment, as 
the placenta is not easily distinguished from the internal face of the uterus itself. — See 
Section on the mode of delivering the placenta when the cord is ruptured. 

t Practical Observations on Midwifery, page 80, American edition. 



THE PLACENTA IS EXPELLED. 363 

placenta et l'uterus," in a practice of twenty years. The cases sup- 
posed to be of this kind, have been simply instances of the hour-glass 
contraction, (placente enchatonne.)* 

1169. This condition of the placenta may be suspected, when the 
uterus continues large, though pretty firmly contracted ; when there is 
a constant issue of blood, and that florid ; when the placenta is not 
within reach of the finger ; and when, after a gentle force is applied 
to the cord, it is found to retract, as if an elastic string had been 
stretched. When the quantity of blood expended from the vagina 
would render manual interference necessary; and more especially, 
when frictions, the exhibition of ergot and other " appliances," have 
failed to stop the discharge, or to expel the placenta, the hand should 
be introduced, and the separated portion of the placenta sought for. 
From this part the hand should take the direction of the adhering por- 
tion, and if it appear that it would require considerable force to destroy 
its connexion with the uterus, every attempt to detach it should be 
instantly desisted from, and only the piece or pieces found loose, or 
not adhering, should be removed; the remaining part must be trusted 
to the efforts of nature. 

1170. There will necessarily be a difference, both in degree and in 
the extent of the adhesion in individual cases. While some may be 
only rather more strict than is usual, others will seem to have the sub- 
stance of the placenta identified with that of the uterus — and, while a 
small portion only may be too adherent in one case, a large one may 
be so situated in another. But in every instance, where there is a 
separated portion, there will be a discharge of blood from the vagina, 
either fluid or coagulated ; and that, in proportion to its accumulation, 
or the activity of the uterine fibres. These cases are almost always 
accompanied by pain, though not of the most severe kind; they, how- 
ever, make but little impression upon the placenta, nor do they much 
diminish the size of the uterus ; yet with each return there is more or 
less blood discharged, and the woman rendered faint by the frequency, 
rather than the quantity evacuated at each contraction, except when 
there is a large portion separated ; then, as in every other instance, 
she will be more quickly exhausted. 

1171. In cases like these, it seems to be agreed; that nothing 
but putting the uterus in a condition to contract, by the removal of 
such portions of the placenta as can be readily detached, will put a 
stop to the flooding, or even moderate it ; and it seems also well 
understood, that even this does not place the woman beyond danger 
— the efforts of nature are not always availing, and the woman dies 
from the mischief created by a retained portion of the placenta. 

1172. Should the discharge continue after a part of the placenta 
is removed, the ergot and frictions should be continued; and astrin- 

• Sicbjld's "Journal de 1'Art des Acconchcments," &,c. as quoted in "Bulletin des 
Sciences Medicales," So. 1. Jan, 1627. p. bZ. 



464 HEMORRHAGE, BEFORE 

gent and detergent liquors should be thrown from time to time into 
the uterus itself, by means of a proper syringe.* 

1173. Let this case be treated with what address it may, it is re- 
plete w-ith danger to the woman ; she may sink from the pertinacity 
of the discharge, or succumb under fever, or other evils excited by a 
putrifying placenta. It is no part of my plan to speak of the subse- 
quent treatment of such cases ; I can, with much confidence, refer, 
for more information upon this head, to the very able treatise of Dr. 
Ramsbotham, just mentioned : and I may here take occasion to say, 
it is not only for this subject, but several others of high interest, I 
would recommend every practitioner of midwifery to the perusal of 
his work. 

d. IV. — Where every thing is as at III. except that the Uterus enjoys 

its full Power. 

1174. This variety is not only less frequent, but is much less 
dangerous, than the one just spoken of; for the uterus, when enjoying 
its full powers, will contract, with sufficient force to prevent any se- 
rious mischief from hemorrhage, though there may be considerable 
waste before the uterus is emptied of the placenta — this requires the 
same manual treatment in the beginning, and the same medical rou- 
tine for the subsequent symptoms. f 

* A considerable variety of substances have been proposed for this purpose; as alum 
and water, wine and water, wine alone, vinegar, &.c. — but, what has answered best in 
my hands, in the very few instances of this kind which have fallen under ray notice, 
has been a strong infusion of chamomile flowers, in which a piece of quicklime has 
been slacked, and permitted to settle perfectly clear. This may be used, moderately 
warm, three or four times a day, or oftener, if required. The common pewter syringe 
for enemata, with a flexible tube attached to it, answers perfectly well — the gum elas- 
tic tubes, for the throat or bladder, may be very readily fixed to the extremity of this 
instrument. In one instance, I saw port wine and waier, with a little alum, used with 
great advantage. 

t There is a variety in this division, which cannot be considered as strictly belong- 
ing to the subject under consideration ;yet its own importance will, I hope, be a suffi- 
cient apology for introducing it here — it is, where the placenta is completely adherent, 
and the uterus powerfully contracts upon this mass, and prevents the introduction of 
the hand, or of even a couple of fingers, for the removal of it, were this even practica- 
ble. It is fortunately of rare occurrence — I have seen but two cases of it, and these in 
the same female, in neither of which was there flooding; indeed, scarcely a drop of 
blood was discharged in the one instance, and in the other only a few srmll coagula 
were expelled, the whole not amounting to four ounces. This case must be trusted to 
nature; for, after repeated examinations, the uterus was not found to relax sufficiently 
even to attempt the removal of the placenta. This mass was expelled entire, on the 
third day, in the one case, without any unpleasant consequences; but, in the other, it 
employed many days before it was thrown from the uterus, and then in small detached 
masses, accompanied with great foetor, thirst, and fever. The patient eventually did 
well, though she remained weak a considerable time. I find that in Europe much less 
anxiety is felt from this condition of the placenta than formerly, but it is always well 
to get as much away as can well be effected without violence, and then trust to nature. 
Dr. Rigby in his valuable little work quotes several writers of distinction, who have 
mentioned it; as Professor Solomon, Dr. Young, &c. The absorption of the retained 
placenta was observed a great while ago, but its reality was much doubted, but is now 
put beyond dispute. 



THE PLACENTA IS EXPELLED. 365 



e. V. — Where there is an entire, or partial Separation, but the Uterus 
in a state of Exhaustion or Syncope. 

1175. This variety is most truly alarming, and requires the most 
prompt and judicious interference, that the woman may not almost in- 
stantly die. The case occurs, 1st. Where a long protracted labour 
has much exhausted the patient, previously to delivery, but where 
delivery has eventually been unexpectedly sudden. The uterus, 
from previous fatigue and exertion becomes enfeebled, though capa- 
ble for the moment of a powerful effort, which suddenly terminates 
the labour, but by which its power is expended — the placenta, from 
the long-continued and frequently repeated pains, was ready to sepa- 
rate, and waited but for the contraction which expelled the child, to 
destroy its connexion with the uterus, to fall loose, or nearly so, into 
its cavity ; and thus give opportunity to the exposed vessels to pour 
out a torrent of blood. 2d. It takes place, and this more frequently 
than from the cause just mentioned, when the labour has been very 
rapid — and where the child seemed to be floated from the uterus by 
a sudden gush of the waters ; under such circumstances, the uterus 
is sometimes instantly deprived of its tonic power, and thrown into a. 
state of absolute syncope, as it has been happily termed by Leroux. 
Or, 3dly. It may arise (and it but too often does,) from the too hasty 
delivery of the child, after the head has escaped through the os ex- 
ternum — here I would wish to caution the young practitioner against 
one of the most formidable errors that can be committed against 
sound practice, or just principles. For, at this moment, the uterus 
has expended much of its power, in pushing the child thus far; and 
if some little time be not allowed it to recover its nearly expended 
strength before the body is hurried through the pelvis, it will be sure 
to increase, and perpetuate the inertia, into which it has just fallen 
from severe exertion : hence we have always to apprehend a flooding, 
where the shoulders are expelled by the same effort that delivers the 
head ; more especially, if the child be large, and the waters but very 
recently expended ; or where the child is small, and the quantity of 
water great, and that but a short time discharged. Should this con- 
dition be accompanied with a partial separation of the placenta, an 
alarming hemorrhage will necessarily ensue ; and if, with an entire 
one, death may be the almost immediate consequence. 

1170. When hemorrhage proceeds from either of the causes just 
stated, it will be evident that nothing but the most prompt interfer- 
ence, and the employment of the most active agents, can prevail 
against so formidable an issue of blood, as now pours from the va- 
gina. No time must be lost by temporizing; the woman will sink 
if not instantly succoured. Frictions upon the abdomen should be 
quickly commenced, and be actively pursued ; doses of ergot — cold 
water poured from a height upon the abdomen, if the frictions do 
not very soon recall the contractile power of the uterus ; and if 
32 



366 HEMORRHAGE, BEFORE 

much faintness from the loss of blood attend, a small quantity of 
moderately strong brandy and water should be given every few 
minutes, until the disposition is relieved : this will pretty soon follow 
its exhibition, if the means for re-exciting the uterus should be suc- 
cessful. Fresh air should be freely admitted, but the feet and legs 
should be kept warm by bottles of warm water or heated flannels; 
the ergot should be instantly given in small but frequently repeated 
doses ; that is, five grains every ten minutes, for two or three 
doses. But should this not excite contraction promptly, twenty 
grains should next be given, and repealed again and again if ne- 
cessary* It is presumed that during this time frictions upon the ab- 
domen and other means would be employed. 

1177. Since the last edition of this work, I have had several in- 
stances of flooding, in which I have had recourse to the ergot with 
entire success ; I can therefore now, and do with much pleasure, 
add my testimony to that of others in its favour. 

1178. But I must here repeat, that my great dependence is upon 
the abdominal friction; having, so far, never known them to fail. 
Some practitioners have introduced ice* into the cavity of the uterus, 
under these circumstances, and it is said with success. I can say 
nothing upon the influence of this remedy from my own experience, 
and were I tempted to employ this substance, I should not judge it 
necessary to conduct it within the cavity of the uterus ; from a be- 
lief, (not, however, I confess, confirmed by trial,) that it would be 
every way as effectual, if it were'iheld in the vagina. I shall illus- 
trate this condition by a case taken at random from a number of 
similar ones — for all these cases are so much alike, as to require but 
one general mode of treatment. 

Mrs. was delivered by a midwife, after a very easy but rapid 

labour of a healthy fine child — the placenta was very quickly ex- 
pelled, as it was found, as the midwife said, loose in the vagina; a 
very profuse flooding immediately ensued, for the relief of which she 
attempted nothing, assuring the friends of the lady it was a common 
occurrence, and from which nothing was to be apprehended — but the 
patient becoming pale and faint, her friends were alarmed, and I was 
sent for in great haste. After my arrival I was informed that the pa- 
tient had been delivered about twenty minutes, and the placenta had 
been extracted about fifteen of that time. When I came to the bed- 
side I was persuaded the patient was dead — no pulse could be felt, 
and for some time there was no respiration ; syncope had just taken 
place. I instantly commenced a brisk friction upon the abdomen — 
ordered brandy and water by the tea-spoonful to be given with fre- 
quency ; warm applications to be made to the feet, and legs — the 
curtains to be opened, and fresh air admitted from the door and win- 
dows, and immediately sent for pills of the acetate of lead and opium. 

* Levret, I believe, was the first who had recourse to this remedy in the manner 
above stated, and it has since been recommended by others— it has lately been advised 
by Mr. Barlow. 



THE PLACENTA IS EXPELLED. 367 

In the course, perhaps, of two minutes after the abdominal frictions 
were commenced, I had the satisfaction to feel the uterus beginning 
to harden under the hand, and every instant after, to acquire more 
and more firmness ; in about ten minutes it was found much dimi- 
nished in size, and much more solid — in the act of puckering itself 
up, a large quantity of coagula and fluid blood were expelled from 
the vagina, which so alarmed the ignorant midwife, to whom was 
consigned the task of watching the discharge, that she declared the 
woman must die if I did not desist from " rubbing the womb so vio- 
lently ;"* but the cause of this poor creature's alarm was to me a 
great comfort, and only induced me the more steadily to persevere 
in the plan of irritating the uterus. 

The disposition to syncope was now much lessened, and the pulse 
could, by a nice examination, be felt returning to the wrist — increas- 
ing in volume and force as the faintness diminished ; and in about 
half an hour more the patient was considered out of immediate risk. 
To guard against a return of the flooding as effectually as might be, I 
directed two grains of the acetate of lead, and a half grain of opium, 
to be given every half hour ; the frictions upon the abdomen to be re- 
newed, should the uterus be found to relax ever so little ; and for this 
end, a very intelligent lady present, was instructed to look for any 
change of this kind that might take place — the brandy and water to 
be given only pro re nata ; and the most perfect rest was enjoined, 
though the position of the patient's body was a very constrained one. 
I again saw my patient in about two hours, (having given orders to 
be instantly sent for, in case of any unfavourable change before I re- 
turned,) and found her situation in every respect improved ; she had 
had no return of hemorrhage, but was occasionally troubled with after- 
pains — her faintness had gone off entirely, and her system was react- 
ing with considerable force — her position was now altered very much 
to her satisfaction ; the brandy and water was stopped, and she was 
permitted, instead of it, to take a few spoonsful of tapioca, seasoned 
with lemon-juice and sugar, from time to time — the pills of the ace- 
tate of lead were directed once in two hours. From this time her 
recovery was as rapid as such a prodigious waste of blood would 
permit; milk was formed in sufficient quantity after rather a longer 
period than usual, and the only subsequent inconvenience she expe- 
rienced was a headach ; which almost invariably follows excessive 
uterine hemorrhage : this was relieved by keeping the bow T els freely 
open. 

* There was nothing to justify her fears ; there was no violence done the uterus by 
the friction; only a persevering and steady action of this kind was kept up, until the 
effect was produced. 



368 



HEMORRHAGE, BEFORE 



f VI. — Where there is either a partial or complete Separation of the 
Placenta , and where the Body and Fundus are in a State of Inertia , 
while the Neck enjoys its tonic Powers. 

1179. This is the most insidious situation in which the uterus can 
well be placed ; and it is one in which inexperienced practitioners 
lose patients more frequently than any other, after the birth of the 
child. The neck of the uterus enjoying its powers, at a time that 
both fundus and' body are in a state of inertia, gives rise to such an 
accumulation of blood within the uterine cavity, as will destroy the 
patient, without its being suspected that such a discharge is going on 
— in this case, the hemorrhage will be concealed ; for a coagulum 
blocking up the os uteri, will prevent either fluid blood, or coagula, 
from issuing; and as there is no apparent flooding, the inexperienced 
accoucheur rests satisfied that all is going on w r ell : nor is he roused 
always from this state of security, until the patient is in articulo mor- 
tis ; or w T hen, perhaps, all human aid would be unavailing. 

1180. This case should warn the practitioner of limited experience 
against a false estimate of the patient's security ; and should teach 
him never to fail ascertaining the state of the uterus, by a careful ex- 
amination, through the abdominal parietes, as already advised. If, 
upon placing his hand upon the abdomen, he find the uterus volumi- 
nous but far from being hard ; if upon inquiry, he learn that there is 
little or no discharge from the vagina ; if he observe his patient be- 
come pale and faint, with a hurried breathing ; if, upon touching the 
wrist', he find the pulse weak, frequent, or extinct, the skin cold and 
clammy, he may be pretty certain there is a concealed hemorrhage ;* 
he has now not a moment to lose, to rescue the woman from an im- 
pending fate — he must be firm, prompt, and self-collected ; and in- 
stantly put in practice every remedy that may promise relief. 

1181. He should commence by abdominal frictions ; and, if he 
find the uterus becoming harder in consequence, he should persevere, 
until he thinks it has acquired a disposition to contract : should the 
hardening of the uterus not be attended with a discharge of coagula, 
&c, from the vagina, he must conclude, either that the neck of the 
uterus is too resisting to be overcome by the contraction of the body 
and fundus without farther aid, or that these are too feeble to over- 
come the resistance of the os uteri, though the latter may be com- 
paratively weak — in either case, he must attempt to give to the uterus 
an increase of power, by removing its contents. 

1182. This must be conducted with much cautious coolness, that 
the remedy must not increase the evil : the frictions upon the abdo- 
men must be entrusted to some proper assistant, and they should be 

* I say, " pretty certain there is a concealed hemorrhage ;" for I cannot say he may 
be altogether certain ; since a rupture of the uterus may be attended with all these 
symptoms. 



THE PLACENTA IS EXPELLED. 369 

kept up with persevering constancy, while the practitioner carefully 
inserts his hand into the vagina ; should he find clots there, he should 
remove them, if they are not immediately forced off by the effort 
which will, most probably, be excited, by the introduction of the 
hand. 

1183. This being done, he is to insinuate finger after finger into 
the os uteri, and gradually attempt its dilatation ; should it be very 
resisting, the resistance must be cautiously overcome; and if this 
be properly conducted, it will, perhaps, never offer such opposition, 
as to render any considerable force necessary — perseverance, in a 
well-directed manner, I am persuaded, will be all that is necessary. 

1184. When the hand has gained possession of the cavity of the 
uterus, the wrist should be so pressed against the side of the neck of 
the uterus, as to make room for the escape of any coagula or fluid 
blood, that may be disposed to issue, by managing in this way, he 
may empty the uterus so gradually, as almost to ensure its subsequent 
contraction, and this will be much aided by the external friction. 
He is now to search for the placenta ;* if it be but partially detached, 
he must cautiously separate the remaining adhesions — when this is 
done with care, and under the precautions above suggested, he is to 
remove it by rotating the hand now in possession of the placenta, 
against the internal surface of the uterus, until it manifests a disposi- 
tion to contract ; and then, and not until then, should the hand be 
withdrawn. 

1185. Should the placenta be found entirely detached, it must be 
delivered with the same regard to uterine contraction. After the de- 
livery of the placenta, pressure and friction should be continued upon 
the abdomen ; nor must these be abandoned, until the contracted 
uterus gives assurance of recovered energy. 

1186. In addition to what has now been directed, the other reme- 
dies which have been suggested should be had recourse to — ergot, 
and cold applications, under the restrictions already proposed, should 
be tried — this case, and the next one to be considered, offer, perhaps, 
the best chances for the ergot ; the brandy and water should not be 
omitted, if the woman be very faint, and much exhausted. The after- 
treatment will suggest itself; and after- symptoms must be treated pro 
re nata. 

* It may be well to observe that, in every attempt to separate the placenta, wc 
should, before wc commence the operation, fix the uterus as firmly as it can well be 
don^, by the external application of the unemployed hand upon the fundus ; in fact, it 
should never be attempted withoutthis precaution ; as the operation is not only very diffi- 
cult, if this be neglected, but is also very uncertain — the woman, if possible, should 
be placed upon her back, as I have directed for other purposes. It may also be proper 
to suggest another caution connected with this operation, which is, that wc be certain 
that we have removed the whole of the placenta ; except in those cases, where it is ex- 
pedient to leave a portion to the natural efforts of the uterus, as in the two adherent 
placenta. It is however, sometimes almost impossible to determine this, where the 
placenta is tabulated as now and then happens. Sec Leroux, Baudelocque, &c. 

32* 



370 OF FLOODING AFTER THE EXPULSION OF THE PLACENTA. 



Sect. VIII. — 8. Of Flooding after the Expulsion of the Placenta. 

1187. When the placenta has been expelled, and is followed by 
flooding, the mode of proceeding is so similar to the last recom- 
mended, that it will require but a few words to make its management 
perfectly clear. In this kind of hemorrhage, like the one we have 
just been considering, it is necessary that the uterus should contract 
before it can possibly be arrested ; therefore it will require the employ- 
ment of all the means already pointed out for this purpose ; and here, 

. as in the other cases, I rest my great dependence upon abdominal fric- 
tions, the acetate of lead, ergot, cold applications, &c. 

1188. Should the concealed hemorrhage take place, it must be 
treated much after the same manner as before the placenta is ex- 
pelled ;* (1179, &c.) that is, the hand must be introduced into the 
uterus, and the coagula suffered gradually to escape, while the uterus 
is gently stimulated by the hand passing cautiously over its sur- 
face ; and when it is found to contract upon it, it may be slowly with- 
drawn ; the after-treatment must necessarily be the same. This case, 
generally speaking, is of much less difficult treatment than where we 
have the placenta to contend with ; and will always, so far as I have 
yet experienced, yield to the treatment proposed, provided a proper 
chance be given to their employment — it cannot be supposed they 
will be availing when the patient is in articulo mortis. 

1189. It sometimes, however, happens, that a portion of the pla- 
centa is left, either entirely, or partially attached to the uterus, which 
will give rise sooner or later to hemorrhage— this may sometimes be 
immediately detected by the inspection of the placenta itself— at other 
times this will be found impossible ; especially in those cases where 
we are under the necessity of bringing away this mass piecemeal — if 
this accident be discovered at once, it is best I believe, to remove it, 
unless it should be a portion that is too adherent. Should this not, 
however, be discovered before the uterus has contracted firmly upon 
it, it will be much better to suffer it to remain, and trust to nature for 
its expulsion, than to run the risk of provoking a flooding ; exciting 
a great deal of pain, or of producing inflammation. But should flood- 
ing attend we must deliver the retained portion, and this can almost 
always be done, as the mouth of the uterus is generally found open or 
yielding when hemorrhage attends ; but should it be found otherwise, 
it must be trusted to the ergot, &c. 

1190. The retained portion of the placenta sometimes may not, 

* This case is sometimes very suddenly fatal. 1 wns once called by a midwife to 
visit one of her patients ; but upon my arrival 1 found the woman dead. The mid- 
wife was much surprised, and could not account for her death ; as " the labour was 
natural and easy, and the placenta had come quickly away." I told her my suspicions 
of the case ; and these were afterwards confirmed, by opening- the body — the whole 
cavity of the uterus was filled with blood, and distended to nearly the size of one at 
the full period of gestation — the mouth of the uterus was found Mifficimtly closed to 
letain the blood discharged from the surface to which the placenta had been attached. 



MEANS FOR PREVENTING HEMORRHAGE. 371 

however, be suspected for several days after delivery; but we have a 
right to conclude that it is retained, when there is frequent return of 
pains, and a discharge of coagulum after coagulum from the vagina, 
followed by fluid blood upon each relaxation of the uterus. When 
the discharge of fluid blood happens in quick succession, and in weak- 
ening quantities, we should immediately attend to the condition of the 
uterus : if it be found sufficiently yielding to admit the hand, it must 
be carefully introduced, and the portion detached, and withdrawn.* 
We may sometimes succeed in detaching it by insinuating a couple of 
fingers into the uterus, and moving them in a circular manner between 
it and the placenta, so as to loosen it, and then remove it either by 
hooking it with the finger, by the natural efforts of the uterus ; or by 
the small crotchet recommended for the removal of the secundines in 
cases of early abortion. If neither the finger nor the crotchet succeed, 
we must trust to nature; taking care to keep the discharge in subjec- 
tion by the tampon. 

1191. The young practitioner is cautioned against treating this case 
with indifference ; it is one not unfrequently attended with danger, 
and sometimes death has ensued very quickly, as La Motte and others 
assure us. Should he be doubtful of his own judgment in this case, 
let him, by all means, (as well as in every other case of danger,) re- 
quest the advice of an older practitioner. 



Sect. IX. — 9. On the means for preventing flooding. 

1192. Having considered at some length the hemorrhages which 
may take place during pregnancy, and such as may follow delivery, 
let me say a few words upon the mode of preventing those which may- 
succeed to labour, as I am of opinion that much may be done to this 
purpose. From what has been said, it will be evident, that whatever 
interrupts the tonic contraction of the uterus, or produces its relaxation 
after it has contracted, will occasion a flooding; provided there be a 
separation of a part, or of the whole of the placenta; it is equally evi- 
dent, that whatever will ensure this contraction, or contribute to it, 
will either prevent or diminish hemorrhage from this part. Much, 
then, will depend upon the manner in which the last stage of labour 
is conducted, to ensure the future contraction of the uterus. 

1193. This subject has been treated by Dr. Denman with much 
apparent interest ; but his advice upon this point is not conformable 
to my own experience. I shall quote his directions in his own words. 
The doctor says, " When I had been attending women who were 

* Baudelocqne tells us he has known this kind of hemorrhage show itself on the 
tenth day, and has been obliged to pass the hand into the uterus, to extract it. (System, 
Viil. IT. p. 27.) I am, however, disposed to think, that in cases of this kind, the ergot 
would be the better remedy ; it should be tried, at least. It is true, that this opinion is 
founded upon its success in a single case. But analogy i.s so much in its favour, in- 
dependently of this, we must repeat it, it should be tried ; it may save both time and 
pain. 



372 MEANS FOR PREVENTING HEMORRHAGE. 

prone to violent hemorrhages after the birth of the child in former 
labours, I have made it a rule to keep them in an erect position till 
the waters were discharged by the spontaneous breaking of the mem- 
branes, and the child was on the point of being born. By this method 
it appeared clearly to me, that the uterus acted more favourably, the 
placenta came away more naturally, and the quantity of blood lost was 
often much more diminished."* 

1194. Now, I ask any one at all conversant with the economy of 
the uterus during, and after labour, how an erect position, the sudden 
evacuation of the waters at the moment " the child was about to be 
born," can contribute to the only circumstance at all available in the 
case under consideration ; namely, the permanent contraction of the 
uterus ? In the first place, an erect position will always be attended 
with a quicker circulation than a recumbent one ; and will permit the 
waters to escape with more suddenness and rapidity; consequently, 
the risk of atony must be increased. It is admitted, upon all hands, 
and among these, by Dr. D. himself, in other parts of his works, that 
if the uterus be too suddenly emptied, there will be a risk of inertia, 
or, at least, of great irregularity of action : if this be so,, how can the 
interest of the woman be improved by this practice ? 

1195. All writers upon midwifery declare, that the sudden evacua- 
tion of the waters, and the delivery of the child almost at the same 
instant, are the most common causes of the atonic state of this organ : 
yet we are advised by Dr. D. to encourage these events, with a view 
to prevent it ? So far all theory is against it ; and I will now appeal 
to experience to prove it to be, at least,, a doubtful practice. 

1196. There was a period of my life at which I looked upon Dr. 
Denman to be the highest authority in midwifery ; and at that time 
almost implicitly followed his instructions upon every point of prac- 
tice ; and consequently upon the subject in question. But in doing 
so, I was persuaded, from sufficient trials of the plan, that it not only 
did not answer the end for which it was proposed, but that it was de- 
cidedly mischievous ; I, of course, abandoned it as soon as I was 
convinced of this truth ; and substituted one almost diametrically 
opposite ; and with which I have every reason to be satisfied. As it 
was impossible to determine, a priori, which patient might be attacked 
with a flooding after delivery, it became necessary to follow some gene- 
ral rule with all, (where practicable,) by which the risk of this acci- 
dent should be diminished. 

1197. It therefore suggested itself that whatever would ensure, 
with most certainty, the tonic contraction of the uterus, would best 
guard the patient against the contingency of a flooding ; and what ap- 
peared to me the most rational to ensure this, was to take off the dis- 
tention of this viscus as gradually as possible, by the early evacua- 
tion of the waters ; to diminish the force of the circulation as much 
as was practicable, by making the woman preserve a horizontal pos- 

* Introduction to Midwifery, Francis's ed. p. 494. 



MEANS FOR PREVENTING HEMORRHAGE. 373 

ture when the pains became urgent ; and to interdict stimuli of every 
kind, as wine, or any other .liquor, heat, and all unnecessary exer- 
tion.* 

1198. But/let me make myself understood, when I say "the early 
evacuation of the waters." It is a fact notorious to every practitioner, 
that the membranes, if left to be ruptured entirely by the force of the 
uterus, would remain entire in many, and, perhaps, in most instances 
until the child was about to be pushed through the os externum. 
Now, were this plan to be pursued, the uterus would be suddenly in- 
stead of gradually emptied ; and consequently the risk of flooding 
would almost necessarily be incurred. But if, instead of this, we 
rupture the membranes as soon as the labour is active, and the os 
uteri sufficiently dilated, or easily dilatable, we should give opportu- 
nity and time for the uterus to contract before the child would be ex- 
pelled, and thus, guard against the evil we are apprehending. The 
uterus would, by this plan, diminish in size in the exact proportion 
to the water displaced ; it would apply itself to the whole surface of 
the child, the inequality of which would serve as an important and 
healthy stimulus, (all things being equal,) and excite it to more cer- 
tain contraction. 

1199. Daily experience proves the justness of this reasoning and 
practice ; for how rarely do we see a flooding follow those deliveries 
where the liquor amnii has been discharged even a few hours pre- 
viously ! — and what can produce the exemption from this accident, 
but the uterus having had sufficient time and opportunity to contract? 
It is true, that this alone may % not always be sufficient to protect the 
woman against a hemorrhage, but I am convinced, from many years' 
experience, it is the principal one.f The directions given for the 

* This is the plan I always pursue, let the labour be under what denomination you 
please, and particularly where there has been a hemorrhage. Dr. Montgomery in his 
late work on midwifery, acknowledges his faith in it, by recommending it, as a safe 
and important improvement in the practice of midwifery. If there be any utility in it, 
the credit at least, as far as I know, is due to Baudelocque, as he undoubtedly recom- 
mended it as long ago, as the first edition of his work. It is, however, the fashion of 
most writers on this subject, to overlook the writing of this excellent authority. 

I at least have recommended it upon the authority of Baudelocque ever since I first 
began to lecture, which was in '96 or 97, aud have been perfec'.ly satisfied with the 
practice ever since. It is true, Dr. Montgomery appears to confine its usefulness only 
for the delivery of the head and shoulders. But that does not entitle him to the merit 
of the thought : for it was easier to limit the idea, than to extend it. 

I would not accuse Dr. Montgomery of a want of reading the more modern autho- 
rities ; but only say, he has strangely overlooked Baudelocque, in this instance. 

f I have, within the last few years, given the secale cornutum a short time previously 
to the delivery of the child, with the happiest effect. It was given, as declared, in the 
following case: — 

Mrs. , aged thirty-three years, in labour with her seventh child. One of her 

friends informed me, that she had always been able to flood excessively very soon after 
the expulsion of the placenta ; and that with the child before the present one, she had 
been nearly exhausted by the profuseness of the discharge. To prevent a recurrence 
of this I prescribed the following mixture : — 

1p. Pulv. Secale cornut. 3ss. 

Sach. Alb. 3iss. 

Aq. Cinnam, Simp. 3 j— M. 



374 



MEANS FOR PREVENTING HEMORRHAGE. 



delivery of the body of the child, after the head has escaped, and the 
abdominal frictions, must also be considered as matters of great mo- 
ment, and should never be neglected, especially with women who 
are " prone to flood" after delivery. 

Of this, one third was given every twenty minutes, about an hour before the child was 
expected to be born. The child was delivered in three quarters of an hour after the 
first dose. The placenta was soon detached, by the efforts of the uterus alone ; and 
was found to be firmly contracted, immediately after. No flooding supervened — in- 
deed nothing but a moderate lochia followed. 

Mrs. , aged twenty-six, of rather a leucophlegmatic habit, and excessively 

afflicted with fluor albus, had with her first child a painful, but active labour of about 
three hours' continuance. Very soon after the delivery of the placenta, excessively se- 
vere after-pains began, accompanied by a pretty profuse discharge of blood and coagula. 
These were repeated in very quick succession, until she became very faint and much 
exhausted. I gave her five grains of the acetate of lead, and sixty drops of lauda- 
num ; frictions were made upon the abdomen. In half an hour the sugar of lead was 
repeated, with much advantage, the pains and discharge were now much abated, and 
the uterus remained pretty permanently contracted. I, however ordered, in case pain 
continued, to repeat the laudanum, without the sugar of lead. She remained very 
weak for a number of days, as she had lost a great deal of blood. 

Her second, third, and fourth labours, were followed by the same disagreeable con- 
sequences ; for in each of which the uterus relaxed itself, after the expulsion of the 
placenta, after having been firmly contracted for half an hour. With her fifth labour, 
May 24, 1827, I resolved upon putting in practice the early rupturing of the mem- 
branes, and the exhibition of the ergot. After her pains became active, I ruptured 
the membranes, though the uterus was not fully dilated. In about an hour the os 
uteri was entirely expanded, and the labour advanced with considerable rapidity ; about 
twenty minutes before I expected delivery would take place, I gave her five grains of 
the secale cornutum, and repeated it in ten minutes, and in ten minutes after I gave 
ten grains more, making twenty grains altogether. Delivery now ensued ; the pla- 
centa was spontaneously thrown off in twenty minutes, unattended by flooding, and 
followed by very little pain. I waited an hour &nd a half, but no hemorrhage took 
place. Thirty drops of the black drop had been given immediately after the first after- 
pain, and this was followed by twenty more. The after-pains ceased, and the lochial 
discharge was very moderate ; in a word, she was better on the third day than she had 
been previously at the end of a fortnight. 

I have delivered this lady four times since May, 1827 — in each labour the same pre- 
cautions were used, with similar happy results. I am of opinion, that were this lady 
neglected after delivery, she would most probably die from hemorrhage ; for with even 
attentions sedulously pursued a strong tendency to relaxation is constantly perceived 
in the uterus, for the first hour after delivery. MM. Trousseau and Maisonneuve, in a 
late paper in the Bulletin General de Therapeutique on Menorrhagia and Metror- 
rhagia, deduce the following conclusions on the action of the ergot in these complaints. 
1st. That the ergot of rye exercises on the uterus a powerful, but transitory action. 
We would advise practitioners to carry with them, always a vial of Tr. of Ergot, and 
when they perceive the uterus flagging, to give a tea-spoonful of it pro re nata in a 
convenient vehicle. 2d. That this action chiefly concerns the fibres of this organ, 
and determines their contraction. 3d. That the state of the uterus in no respect in- 
fluences the production of the pains. 4th. That the pains are observed even when a 
part of the neck of the uterus is affected with cancer. 5th. That the ergot acts on 
the centre of the nervous system as a narcotic. 6th. That the resulting phenomena 
are slow, but durable. 7th. That they are never dangerous when we confine ourselves 
to combat the menorrhagia. 8th. That the dose may without danger or inconvenience 
be carried to several drachms, in the course of four or five days. 9th. That in the 
treatment of menorrhagia, divided doses, given at equal intervals, are to be preferred. 
Lastly, That we need be under no apprehension of commencing with a drachm dose, 
divided during the first twenty-four hours." — American Journal of Medical Sciences for 
Aug. 1833, p. 515. 



ASSISTED DELIVERY OF THE PLACENTA. 375 



CHAPTER XXXII. 



OF THE ASSISTED DELIVERY OF THE PLACENTA. 

1200. The tonic contraction almost exclusively detaches the pla- 
centa from the uterine surface, in order that it may be expelled. 
This takes place at various periods after the delivery of the child, 
as the tonic power of the uterus may be in greater or less perfection, 
or as the connecting medium of the placenta and uterus may be more 
or less dense — it will, therefore, be found, that the placenta may be 
cast off immediately after the expulsion of the child, or it may re- 
quire some time to effect this end, without considering it to be a 
morbid adhesion of this mass.f 

1201. It is desirable at all times, that the placenta be expelled 
pretty quickly after the child. And if this do not take place spon- 
taneously in due time, it is proper that we should give such assist- 
ance, as will facilitate its exit, without the introduction of the hand. 
There has been much diversity of opinion, what period or interval, 
constituted " the proper time," for the extrusion of the placenta — 
some fixing a longer, and others a shorter term, much to the embar- 
rassment of the young practitioner — but this point, I conceive, is 
easily settled, by taking the indications from the condition of the 
uterus itself, and not from the number of minutes or hours which 
may have elapsed. 

1202. I have always objected to making "time" the criterion for 
action in midwifery ; and my aversion is by no means abated when 
an attempt is made to make it a rule for the delivery of the placenta; 
for the same objections must obtain here, as in the cases I have al- 
ready declared it should not govern in. I have stated (1200) by 
what power the separation of the placenta is effected, and that it 
would necessarily require a longer or shorter interval, as the agent 
may be more or less active. It will follow, then, that the expulsion 
of this mass may be either very prompt, (1200) or be rather tardy; 

* Xo point of practice i< more unsettled than the time that should elapse between 
the attempt to deliver the placenta and the delivery of the child. I am averse as I 
have elsewhere declared, from making time the criterion for action, especially as there 
is a sure and never-failing guide that leads us to a safe and happy issue. It is cer- 
tainly always safe to act when the uterus is well contracted, and never is until then. 

may remark, in general, that the time the uterus requires to throw off the 
placenta, is in some measure indicated by the state of the foetal circulation— if this be 
quickly i' terru[»ted after the birth of the child, the placenta will be detached soon ; if 
the circulation continue, it will require more time. This may be easily understood ; 
as either of these circumstances betrays the want of proper force in the tonic contrac- 
tion, or that it enjoys to a proper extent. 



376 ASSISTED DELIVERY OF THE PLACENTA. 

I have already pointed out the duty of the accoucheur in the first 
instance, and the mode by which he is to execute this duty, (556;) 
I shall, therefore, in this place, only consider what is to be done in 
the latter case. 

1203. I have stated in effect, (1200) two principal causes for the 
tardy separation of the placenta ; namely, 1st. A diminution of the 
tonic power; and 2d. Too great a firmness in the connecting me- 
dium of this mass with the uterus ; each of which requires a little dif- 
ference in management. The first of these may be known, 1st. By 
the uterus being rather larger and softer than it should be, a short 
time after delivery; 2d. By no portion of this mass being within 
reach of the finger when introduced into the vagina ; 3d. By there 
being no return of the alternate contractions of the uterus; and 4th. 
When a force is applied to the cord, it gives the idea that the pla- 
centa is descending ; but this being fallacious, for so soon as we 
cease to draw upon the cord, it instantly mounts again into the 
pelvis. 



Sect. I. — 1. Mode of acting in Retention from want of Tonic 

Power. 

1204. When this state of things presents itself, all attempts to de- 
liver the placenta must be forborne until we have, by properly in- 
stituted frictions over the region of the uterus, obliged it to contract 
and harden itself under the hand ; and at the same time retire lower 
into the pelvis — when these alterations show themselves, we almost 
always find they will be accompanied by pain ; and if we now co-ope- 
rate in a proper manner, we shall find the placenta to arrive within 
reach of the finger, and announce its separation by a small discharge 
of fluid blood, or coagula, or both, and fall into the vagina, from 
whence it may be extracted, as has been directed, (556.) 



Sect. II. — 2. Retention from too firm Adherence. 

1205. In the second case, (1203) we shall find the uterus reduced 
in size ; firm and pretty well sunk in the pelvic cavity ; and may be 
even attended with pain, without bringing the placenta within reach 
of the finger, and if we draw upon the cord as in the other case, 
there is little or no retraction after we intermit the force. 

1206. This case requires, for the separation of the after- birth, not 
only a firmer contraction of the uterus, but a longer continuance of it ; 
as well as a particular application of force to the placenta itself, by 
means of the cord. Force, to be successfully applied for the se- 
paration of the placenta, must be directed in such a manner, as to 
act perpendicularly to its surface ; or its influence will be destroyed 
— to effect this, we must first ascertain the part of the uterus to which 



ASSISTED DELIVERY OF THE PLACENTA. 



377 



this mass adheres. This is to be known by observing the part of the 
pelvis to which the funis seems inclined ; as this will point out the 
portion of the uterus to which the placenta is adherent — thus, if the 
cord descend behind the symphysis pubis, the placenta will be 
attached to the anterior part of the uterus; if before the projection of 
the sacrum, it will be found at the posterior part of the uterus ; if 
to either side, the placenta will be at the side on which the cord is 
found. 



a. Mode of Acting in this Case. 

1207. Having ascertained the location of the placenta we must so 
arrange a couple of fingers within the vagina, that drawing the cord 
horizontally will act in the desired direction upon it; that is, if the 
placenta be attached to the anterior portion of the uterus, we place 
the cord behind the fingers, and press it back towards the projection 
of the sacrum, while we draw the cord with the other hand ; if to the 
posterior portion, we place the cord before the fingers, and carry it 
as high as we can well reach, towards the superior strait, and then 
draw with the other hand : if placed at the lateral portions, we must 
introduce the fingers of either the right or left hand, as it may be the 
right or left side of the uterus to which the placenta is attached, and 
then place them in such a manner that the horizontal drawing will 
act in a proper direction — if the placenta be at the left side, we must 
introduce the fingers of the right hand, and vice versa. By acting 
thus, we may succeed in bringing down a placenta, which, without 
it, might require the introduction of the hand. 

1203. In this situation of the placenta, (1203) we are almost cer- 
tain to have the co-operation of the alternate contractions of the 
uterus ; and it is proper that we take advantage of them, by making 
gentle exertions by the cord at the same time ; if no pain come on, 
we should solicit the farther contractions of the uterus, by frictions 
and moderate pressure upon it, while we gently and steadily pull at 
the cord. We should now and then ascertain if the placenta is de- 
scending: this is best done by slacking the tractive force ; and then 
observe whether the cord remounts, or whether it remains station- 
ary. If it ascend, we may be certain that the placenta is either not 
detached, or that the uterus is not aiding in its expulsion — in such 
case, we should be very careful that the degree of force applied to 
the cord, be not sufficient to destroy its union with the placenta ; and 
that we do not urge its deliverance too importunately. 

1209. If wc find the cord not to remount, or if it remount but very 
little after we have ceased to draw, we may be assured the pla- 
centa is descending, and will occupy more or less of the vagina; 
from whence it may be easily extracted, as it is now within reach 
of the finger. 

1210. It very rarely happens that the introduction of the hand is 
33 



378 ASSISTED DELIVERY OF THE PLACENTA. 

necessary to deliver the placenta, in the situations I have just de- 
scribed ; method and address, are all that are required to overcome 
the existing difficulties; and, perhaps, there is no other condition of 
this mass, in which it has been so often, and so wantonly, dragged 
from the uterus, because a little resistance was offered by the causes 
just stated. It would seem to be a sufficient reason with very many 
inexperienced practitioners to introduce the hand for the delivery 
of the placenta, because it does not immediately precipitate itself 
into the vagina after the birth of the child ; or does not instantly 
obey the force that is applied to it ; however ill-directed, or inop- 
portune, that attempt may be. 

1211. Or if the practitioner be timid, and obey a direction but 
too common in books upon this subject, that a certain period of 
time must elapse before any attempt be made to deliver the pla- 
centa, he may let the proper moment elapse for the successful 
application of a well-directed force and thus convert a case of 
great simplicity into one which will require the aid of art. 

1212. 1 say, that the time for interference of the accoucheur for 
the delivery of the placenta, should always be regulated by the con- 
dition of the uterus itself; and that condition is, whenever it is 
firmly contracted — this rule, I believe, will never deceive; or, at 
least, I have uniformly acted upon this principle; and so far, 1 think, 
I am safe in saying, I have not had cause to believe it wrong. I 
acknowledge that some address is required for the successful de- 
livery of this mass; but as this is easily acquired by a proper atten- 
tion to the laws by which it is expelled, I should hold that man in 
some measure accountable, if he produced mischief, by an improper, 
or ill-directed manoeuvre. Time, simply considered, can never 
form a safe rule for the delivery of the placenta; the degree of con- 
traction of the uterus, alone can point out the proper moment to 
operate, or teach us when it would be improper to attempt it. 

12 13. I am decidedly of opinion, that the necessity for artificial 
delivery of the placenta is often created by obeying a rule taken 
from time, let that period be longer or shorter; for time, in itself, 
can neither produce the conditions required, nor command them if 
they be absent. For the uterus may be disposed to throw off the 
placenta, and it would do so if properly aided, long before the fixed 
period may arrive ; or it may be in a state of such feebleness at 
that moment, as to render it highly dangerous to attempt it — hence, 
on the one hand, an injury may be done to the uterus by the 
manual delivery of the placenta, by the resistance which it now 
offers to the attempt ; or the woman be exposed to a severe and 
perhaps a fatal hemorrhage, by our acting at the limited moment ; 
it is, therefore improper, to permit the uterus to contract by im- 
properly delaying the* moment to act, so as to enclose this mass, 
and require force to open it; or by inattention to its state of im- 
perfect contraction, to induce a flooding, by acting, because a 
specified time has elapsed 



ASSISTED DELIVERY OF THE PLACENTA. 379 

1214. Should a portion of the placenta be separated, and a flood- 
ing accompany these conditions of the placenta, it must be treated 
as directed for in this case. (1147, &c.) 



Sect. III. — 3. Of the Delivery of the Encysted Placenta. 

1215. In consequence of the contraction of a portion of the body 
of the uterus, before the placenta is delivered, it is sometimes con- 
fined in a distinct apartment, as it were, of this organ ; and this 
agreeably to my own experience, is always at the fundus. The 
mechanism of this accident is easily understood, if we recollect the 
strong disposition the body and especially its lower part, has to 
contract, or narrow itself, when the distending cause is removed ; 
and especially while the placenta remains undelivered. 

1216. Some have thought this contraction could take place only 
when the placenta was attached to the side of the uterus; and others, 
only when it adhered to the fundus; of this last opinion was Baude- 
locque; and it entirely comports with my own experience of this con- 
dition of the uterus — indeed, I might say limited experience ; for such it 
truly is; as I have very rarely met with it: and never, so far as my 
recollection may be depended upon, when I have had the entire 
management of the case. Dr. Douglass, of Dublin, has considered 
this condition of the uterus altogether artificial or arising from 
some irritation near the mouth of this organ; either by acting upon 
the cord or by the introduction of the hand. 

1217. He says, " the exciting cause of the uterus assuming the 
hour-glass form is iritation, produced either in the vagina by inju- 
dicious pulling at the umbilical cord, or in the cervex uteri, by the 
accoucheur's hand searching there in vain for the placenta." 

1218. " That the proximate cause is a spasmodic constriction of 
the muscular fibres of the uterus at the lower verge (not the centre) 
of that section termed its body, and just where it ceases to be 
thickly muscular." 

1219. "Thence I conclude," says the doctor, "that this hour- 
glass contraction is not produced by any principle of action inherent 
in the uterus itself, and that whenever it does occur, it is caused by 
mismanagement. " 

1220. " Therefore, in order to avoid such occurrences, the practi- 
tioner should always refrain from exciting unnecessary irritation." 

1221. " And in those cases of unavoidable retention of the placenta, 
wherein it may be necessary for the accoucheur materially to interfere, 
he should, having cautiously inserted it within the vagina, push his hand 
briskly up to the very fundus of the uterus. And in this operation he 
should direct the hand forward towards the umbilicus." This case is 
seldom or never attended by hemorrhage.* 

* I was called not Ion? since to a case of this kind", in which, as T was informed by 
the gentleman who had charge of the case, that the patient had suffcicd a considera- 



380 ASSISTED DELIVERY OF THE PLACENTA. 

1222. This case may be known by the fundus of the uterus reach- 
ing higher than common ; by its being smaller in its transverse direc- 
tion, as can be detected through the abdominal parietes ; by an 
elastic feel of the cord ; by no pain attending ; by the placenta not 
being within the reach of the finger ; and if upon the introduction of 
the hand, the cord is found to pass through an aperture of greater or 
Jess size, and the placenta felt to lie within the cavity formed by this 
contraction. 



a. Mode of Operating in this Case. 

1223. In the hour-glass contraction of the uterus, it becomes al- 
ways a matter of necessity to operate, and this should be undertaken 
as soon as this situation is ascertained ; as I believe no advantage has 
ever been derived from waiting. It is in vain the action of the uterus 
is solicited ; or that force, however well directed, be applied to the 
cord ; nothing but the introduction of the hand, and that made to pass 
the stricture, can relieve the placenta from its confinement. 

1224. The woman should be placed upon her back, as directed for 
turning (732,) or the application of the forceps, (755 ;) the hand must 
be cautiously introduced into the vagina, and forwarded agreeably to 
the direction of the cord, which should be taken always for a guide. 
•This will be found passing through an aperture of uncertain size ; 
sometimes larger, sometimes smaller ; into which the fingers, one 
after the other, must be introduced and its dilatation gradually ef- 
fected, until the whole hand is enabled to pass the stricture.* When 
the hand has possession of the chamber which contains the placenta, 
this mass must be separated carefully if it be adherent,! or if loose, it 
must be seized with sufficient firmness to secure its following with the 
hand w T hen this is withdrawn. 

1225. Some little management is required in withdrawing the pla- 
centa, or rather in the mode of seizing it — it must not be grasped by 
the whole hand, and kept in it by contracting the fingers ; for its bulk 
with that of the hand, will exceed the opening through which it has 
to pass. This is not an unusual predicament, and has sometimes been 

ble loss of blood — this appeared to have been the case, as I found the patient was very 
much exhausted on my arrival — she, however, did well. 

* We do noi recommend the direction just given by Dr. Douglass, (1221,) "to 
push the hand briskly up to the very fundus of the uterus." On the contrary, this 
operation should be deliberately and cautiously performed, or much mischief may 
ensue ; for such is the resistance sometimes offered by the constriction, that it 
would require much force to overcome it, especially if it be suddenly applied. And if 
suddenly applied might injure the connexion of the uterus with the vagina. — See pars. 
1226, 1227. 

+ Dr. Douglass says,, it is always found adherent, or rather that it is never found 
detached. (Observations on the Hour-Glass Contraction of the Uterus, p. 10.) Dr. 
Samsbotham says, that it is generally found detached, (Practical Observations, Am. ed. 
p. 144,) and thi3 comports with my own observations. 



ASSISTED DELIVERY OF THE PLACENTA. 381 

attempted to be overcome by force, to the discomfiture of the operator, 
and the serious injury of the patient. 

1226. During the introduction of the hand into the uterus, and 
especially while contending with the stricture, the uterus must be 
firmly fixed by the other hand being pressed upon its fundus, until 
possession is taken of the placenta, and the hand is about to be with- 
drawn. After the after-birth is delivered, I have thought it best to 
re-enter the uterus to the very fundus, so as to be certain that neither 
a portion of the placenta nor coagula are left behind. 

1227. This operation is always to be slowly and cautiously per- 
formed, as the woman may be much endangered by a contrary prac- 
tice — she may, by rudeness and want of tact, be liable to subsequent 
inflammation of the uterus, or its immediate rupture. It is to the pa- 
tient always an operation of severe suffering, however well conducted, 
unless the stricture resists but very moderately; therefore, to add to 
it by rudeness or mal-adroitness, is both cruel and dangerous. 



Sect. IV. — On the enclosed and partially protncded Placenta. 

1228. It sometimes happens that the placenta is confined in the 
uterine cavity, though detached from its surface, in consequence of 
the sudden contraction of the mouth of the uterus. It would, per- 
haps, be difficult to assign the reason of this disposition in the mouth 
of the uterus to close, before the placenta is expelled — it may arise 
from some peculiar stimulus, or from some preternatural irritability of 
this part of the organ, over which we have no control. 

1229. This situation of the uterus and placenta may be known by 
the latter being unusually long detained, when from the hardness and 
well contracted condition of the former, we should not have anticipated 
such delay; by the force applied to the cord, not making the placenta 
descend ; by an absence of hemorrhage ; nay, almost of discharge ; by 
the contracted condition of the os uteri, by the placenta being felt 
when the finger is passed through it; and by the absence of pains. 

1230. It would be in vain to attempt the delivery of the placenta 
by any exertion made upon the cord, though this is almost always 
resorted to ; and as the whole of the uterus will sink lower into the 
pelvis by this effort, the inexperienced practitioner imagines that the 
placenta is descending — he continues his traction under this illusion, 
and thinking a little more force will overcome the difficulty, he mul- 
tiplies it; the cowl is ruptured, and his difficulties are increased — he 
now becomes alarmed ; and the panic spreads to the patient and her 
friends; every thing is thrown into confusion; a consultation is de- 
manded, and a rival practitioner robs him of the little reputation he 
rn.iy have acquired, and thus interrupts his progress in business. Or, 
fearing the consequences a discovery of this accident might produce, 
he disingenuously conceals it; and attempts, without method, the 
delivery of the imprisoned placenta, to the immediate torture and the 

33? 



382 ASSISTED DELIVERY OF THE PLACENTA. 

subsequent injury of his patient. Not knowing exactly what causes 
the delay, or the nature of the difficulties which oppose him, after ex- 
cruciating his patient, by unavailing efforts, he, in a paroxysm of 
mental anguish, abandons her, and declares the case must be left to 
nature. 

1231. The modes of proceeding in such cases, are, 1st, to recall 
the contractions of the body and fundus by the exhibition of the ergot 
in common doses ; and, 2dly, should this not succeed within an hour, 
the uterus must be gently entered by slowly dilating the os uteri, and 
the placenta removed— this, if carefully and methodically attempted, 
is not so difficult as might at first be imagined. The woman should 
be placed as directed for turning, (732,) and during the passage of the 
hand through the os uteri, the uterus should be firmly supported as 
suggested, (1226.) 

1232. I have ventured to suggest the exhibition of the ergot in this 
case rather from analogy, than experience — as in a case of retained 
placenta, after a premature labour of the seventh month, and another 
under similar circumstances at the sixth month, I happily procured 
the expulsion of these masses by this remedy.* 

1233. As a general rule, I am of opinion, that the sooner we ope- 
rate, all things, being equal, the better, as the obstinacy of contraction 
is in proportion to the lapse of time, unless the alternate contraction 
of the uterus come into our aid. i 

1234. There are three other situations of the placenta, which may 
be regarded as varieties of this case ; the first is, where a small portion 
of this mass is pushed through the os uteri - T the second, is where about 
one-half has escaped ; the third, is where the greater part of this mass 
is without the mouth of the uterus. In all these instances, the farther 
progress of the placenta is prevented, by the os uteri firmly embracing 
it ; at least so firmly as to render the attempt to relieve it by the cord, 
not only fruitless, hut, perhaps, mischievous, by causing its rupture. 



Mode of Acting in each Case. 

1235. If the placenta be found in the first situation enumerated, 
(1234,) we may procure its descent, by employing the crotchet re- 
commended for the delivery of this mass, in cases of flooding from 
abortion, (see figure in Treatise on Diseases of Females, chapter on- 
Uterine Hemorrhage, by the author,) or by dilating the os uteri as re- 
commended, (1224,) first pushing up the protruding portions. 

* I must, however, observe, that I have no doubt of the sufficiency of the "ergot" 
to procure the discharge of the placenta after the birth of a child at full time, though 
I cannot give a proof of it. The analogy between the two cases under consideration, is 
too strong to admit a doubt upon the subject, though the occasions for the employment 
of this article, will, from the very nature of the economy of the uterus, be much more 
rare in cases which arrive at full time than those in which delivery takes place pre«. 
gaaturely., 



ASSISTED DELIVERY OF THE PLACENTA. 383 

1236. For the second condition, the hand must be introduced into 
the vagina, and a finger passed under the edge of the os uteri, by 
which successive portions of the placenta must be hooked and brought 
downward, until the whole is relieved. 

1'237. In the third instance, all that is required is, the introduction 
of the band into the vagina, and the firm seizure and compression of 
the placenta, as near the os uteri as possible ; compression near the 
stricture diminishes the bulk of the placenta so much as to permit it 
to escape, by drawing the whole mass toward the os externum. 

1238. The cases I have just described, are far from being uncom- 
mon ; and few offer greater embarrassment to the inexperienced prac- 
titioner. The cause of the detention of the placenta in many cases is 
not sufficiently well understood, or sufficiently early ascertained, to 
render diem free from risk. I, therefore, recommend to the young 
practitioner, to search for this mass whenever any unusual delay in its 
delivery takes place, though the case be not attended by flooding, or 
other accident, provided he has previously put in practice all the 
means which are usually essential to its expulsion, and they have 
failed; or, having waited until the condition of the uterus, as ascer- 
tained by the hand through the abdominal parietes, gives evidence 
that it has contracted sufficiently, if not successfully.* 



Sect. V. — 5. Of the delivery of the Placenta, when the Cord is broken 

or is very feeble. 

1239. An undue force applied to the cord with a view to deliver 
the placenta, may rupture the funis ; hence, the important caution, of 
not applying too much. It sometimes happens, however, that a very 
moderate force will destroy its connexion with the placenta — this may 
arise from a weak state of this production, though it may be sound ; 
it may arise from a morbid condition of it, or from its being in a 
state of putrefaction. 

1240. Those who are in the habit of seeing many cases of mid- 
wifery, can pretty well judge of the firmness or strength of the cord, 
so soon as they see it; and will regulate their endeavours to extract 
the placenta by it. When the funis is frail, or very tender, it 
should never be used as a means to deliver the after-birth ; it should 
always be preserved as a guide for the hand, should it become neces- 
sary to enter the uterus. The rupture of the cord, in itself, does not 
necessarily create difficulty ; since, if this part be very delicate, we 
do not employ it in our attempts to free the uterus of the placenta — 

* F r the mode <>f acting in " placental presentation?," under all their various forms, 
sec c ; apter on M Unavoidable Hemorrhage ;" for the plan of proceeding in hemorrhagy 
from I pTrtial «e: aration of the placenta; for the rule of conduct where it is too adherent, 
and attended by flooding; for rules to be observed in hemorrhage from atony of the 
uterus after separation of the placenta, Sec; see section on u Hemorrhage before the 
placenta is Expelled," &c. 



384 ASSISTED DELIVERY OF THE PLACENTA. 

therefore, in such cases, the placenta derives no advantage from its 
preservation, as regards its unaided delivery ; but it may be of im- 
portant service, should it be necessary to relieve it by the hand. 

1241. It will follow from what has been said, (1240,) that it is not 
always necessary to make an artificial case of a ruptured cord ; for 
the expulsion of this mass is nowise promoted by its preservation, if 
the cord be too feeble to act with it ; delivery, therefore, in such case, 
must depend upon the spontaneous efforts the uterus makes to clear 
itself of this burden, and not upon any force that may be*applied to 
the funis. 

1242. But, though the preservation of the cord may not aid us in 
our attempt to deliver the placenta when it is too tender to be an 
agent, yet it is highly important, notwithstanding, that it should be care- 
fully preserved ; especially as we cannot determine a priori, the cases 
in which it may be necessary to deliver this mass, artificially ; for, 
during its continuance within the uterus, some accident may attack 
the patient, and render it indispensably necessary to interfere and 
hasten its delivery. 

1243. It may, however, be remarked, as a general rule, that the 
placenta is longer in descending when we cannot aid it by the cord, 
or when the cord is separated from it, than when it is strong and pre- 
served — the reason is obvious. We should, therefore, in such cases, 
promote the contraction of the uterus by frictions : and, from what J 
have experienced of the action of the ergot, (1221,) I should be in- 
duced to give it a trial before I would pass the hand into the uterus ; 
for the hand should not be introduced until it has been satisfactorily 
proved that the ergot had failed. 

1244. Should we not succeed by these means in relieving the uterus 
of its burden ; and, especially, should any accident complicate this 
period of labour, we must introduce the hand, and deliver the pla- 
centa. The difficulty in this case is no greater than in common cases, 
provided the cord, (however feeble it may be,) is preserved ; since 
this will, with proper management conduct us to the placenta, as cer- 
tainly as a stronger one — but if it be separated, a great deal of em- 
barrassment may be sometimes created, by not being able to distin- 
guish the placenta from the uterus, if this mass be not detached ; if it 
preserve its connexion with the uterus, the unskilled hand will find 
much difficulty in distinguishing it from the surface of this organ. 



a. The signs by which the placenta may be detected. 

1245. The following marks will, however, lead to the detection of 
the placenta ; 1st. If the fingers pass over the internal surface of this 
body, its vessels, distended by blood, will generally be distinctly 
felt. 2d. If the placenta be pressed by the fingers, the woman will 
scarcely perceive their presence ; whereas, if the uterus be touched, 
she will complain. 3d. If the hand be placed over the uterus, exter- 



ASSISTED DELIVERY OF THE PLACENTA. 385 

nally, opposite the one within the uterus, the thickness of the parts 
will declare whether it be the placenta which interposes between them, 
when this mass is on the anterior part. 



b. The mode of acting in this Case. 

1246. When it is ascertained that the hand is in contact with the 
placenta, the latter must be cautiously separated from the uterus, by 
insinuating the fingers between them. There is sometimes a difficulty 
in getting behind the placenta, in consequence of the membranes in- 
terposing between the hand and the surface of the uterus. To over- 
come this hinderance, the hand should be placed behind the mem- 
branes, and then permitted to travel up the placenta itself, and effect 
the separation. 

1247. Should the placenta be found loose in the uterus, it must be 
taken hold of and withdrawn. 

1243. I have a few times met with difficulty in the delivery of the 
placenta from its excessive size. These instances have uniformly 
occurred in cases of premature delivery, or rather where the delivery 
was not premature, but where the child had died some time before 
its birth. In the particular cases alluded to, the children were not 
found putrid ; but, on the contrary, were hard and rigid, though a 
little swoln ; the funes were always much enlarged, very tender, and 
engorged with a brown blood ; the placentae w 7 ere found in these cases 
to distend the uterus so much, as to give the suspicion, to those unac- 
quainted with the nature of such cases, that there was a child remaining 
in the uterus. 

1249. In looking over my records of these cases, I do not find one 
that did not require the introduction of the hand for its deliverance; 
and, in two of these, the placentae w T ere so enormously large, as to 
nearly fill a common-sized chamber pot. This prodigious increase 
appeared to belong to the infiltration of water into the meshes of the 
placenta. In all the cases of the kind now under consideration, no 
aid was derived in the delivery of the placentae from the funes, as 
they were uniformly found so frail as not to permit any force to be 
applied to them. 



386 PUERPERAL CONVULSIONS. 



CHAPTER XXXIII. 



OF PUERPERAL CONVULSIONS. 



1250. This truly frightful disease may attack a woman, perhaps, 
at any period of utero-gestation ; but more frequently after the sixth 
month. Dr. Lyman says, " it seems to be a question with some 
writers, whether the disease we are considering ever attacks antece- 
dently to labour. I believe we may very safely answer this in the 
affirmative. I do not recollect having seen it earlier 4han the latter 
part of the seventh month."* 

1251. I do not recollect at this moment having met with any writer 
who has questioned the liability of the pregnant woman to convul- 
sions. I am certain this opinion must be wrong, as I have witnessed 
a number of cases of convulsions where labour was not present, and 
where there was no reason to believe this process had any agency in 
their production, f That women are much more liable to this disease 
when this process is about to commence ; or after it has advanced, is 
agreeable to all observation ; and that labour frequently follows a few 
days after, as Dr. Lyman observes, is equally true : for we believe 
with him, that the parturient effort has very often, either a direct or 
indirect agency in their production ; or, in other words, is the exciting 
cause. The cause assigned for convulsions have been various ; some 
have supposed they arise from some peculiar irritation of the uterine 
fibre from pregnancy ; others considered them truly epileptic ; while 
others regard them as nervous, or hysterical. 

1252. This difference in views, necessarily leads to a difference in 
treatment' — the first, make^ safety consist alone in immediate delivery ; 
the second, forbids the practice ; while the third, relies upon the use 
of opium. From what I have seen of this formidable complaint, I am 
persuaded, that there is no one cause constantly operating to produce 
puerperal convulsions ; nor is there any one mode of cure applicable 
to all cases. To be successful in the management of this complaint, 
it is necessary that attention be paid to the species of this disease, 
with which the woman may be attacked ; I have, therefore, from a 
conviction that they do not all depend upon one and the same cause, 
divided them into, first, epileptic^ second, apoplectic ;§ and- third, 

* New England Journal, No. VI., Vol. III. third Series ; p. 344. 

t See note to case 8th. 

t We do not pretend by this term to insist on its character being the same as hi 
true epilepsy — the term is only adopted, from the want of one more strictly, ^perhaps, 
appropriate. 

§ "The adjective appellation of this form of the disease, points out at once its dis- 
tinguishing features — the oppression and stupor are more marked, the convulsions 
more heavy and embarrassed, the respiration stertorous, the pulse slower and fuller 



PUERPERAL CONVULSIONS. 387 

into the hysterical ; each of which may attack under two distinct con- 
ditions of the uterus, and requiring from that circumstance a difference 
of management. 

1253. Convulsions are almost always preceded by symptoms which 
denote their approach ; in the epileptic species, the premonitory 
symptoms may exist a number of days before convulsions show them- 
selves ; it is uniformly attended by a strong determination to the 
head, producing an engorgement of the vessels ; hence headach, of 
greater or less intensity, ringing of the ears, a temporary loss of vi- 
sion, giddiness, &c, are always present before the convulsive stage 
shows itself. From these symptoms being followed by convulsions, 
I have always, when consulted upon such occasions, advised the im- 
mediate loss of blood, pretty smart purging, and an abstemious diet. 
By thus anticipating the attack, I feel assured I have in a number of 
instances, prevented this terrible disease. 

1-254. Some are attacked by a severe pain in the stomach, which 
Dr. Denman considers as more fatal than when the head is the seat 
of pain : of this I can say nothing from my own experience. I may 
remark, that the longer the premonition, the milder the attack appears 
to be. In the most suddenly fatal case I ever saw, the patient sud- 
denly cried out, " My head, >my head!" convulsions instantly ensued, 
of which she died in a few hours. — See Case IV. 

1255. Pregnant women may be attacked with convulsions from 
causes not connected with gestation, or at least with labour — as the 
attack is not accompanied with any signs of it. These, if my obser- 
vations be correct, are more unmanageable and fatal, than when preg- 
nancy may be the remote cause. When pregnancy is instrumental 
in the production of convulsions, it is almost always at that period, 
when the uterine fibres are at their greatest stretch ; where the os 
uteri is disposed to dilate ; or where they suffer from some peculiar 
irritation, over which we have no control, or some inconvenience 
from the contents of the uterus, which has the same effect; and such 
convulsions are almost always of the epileptic species. 

1256. These convulsions, so far as my observations have extended, 
are never preceded by an aura, as in epilepsy, properly so called. 
But after the patient has suffered for a longer or shorter period the 
-\mptoms just named, (1253,) she is seized with quickly repeated 
spasms — the face and eyes are twitched in all possible directions, 
with incredible quickness — the arms, legs, nay, the whole body, is 
violently agitated — one side is sometimes more affected than the 
other ; the face becomes flushed, livid, black ; the tongue is strongly 
thrust forward between the teeth, by which it is almost always se- 

and the pupils less obedient to light, than in either of the other forms. The attack 
is also usually more gradual, being very often (I believe always,) preceded by signs of 
cerebral fulness, the muscular system is relaxed, and as it were, dead, &c. There are 
other signs enumerated by M. Velpeau, which T never rtmember to have seen ; his 
account of this disease has not been drawn, I fear, at the bed-side. Velpeau's Treatise- 
convulsions chez les femmes pendent les process, &.c. 



388 PUERPERAL CONVULSIONS. 

verely wounded. Respiration at first is much hurried, and eventu- 
ally becomes almost suspended ; the carotids beat violently; the jugu- 
lars are much distended ; a peculiar sibilating noise is made by the 
mouth, not unlike what is termed "a cat spitting;" froth issues 
from the mouth, tinged with blood from the wounded tongue. The 
pulse in the' beginning is full, frequent, and tense ; but quickly be- 
comes rapid, small, and eventually almost imperceptible ;* the urine 
and feces are sometimes discharged involuntarily ; a cold clammy 
sweat bedews the whole body, and the fit begins now to decline. 

1257. The convulsive motions gradually subside — they never 
cease suddenly and at once — their force and frequency abate ; the 
pulse becomes more distinct and less frequent ; the breathing is less 
hurried, and less oppressive ; the face loses part of its lividity; the 
muscles are agitated but at intervals, and their action resembles the 
commotion excited by passing a brisk electric shock through them, 
and eventually they sink into repose. The patient, however, remains 
for the most part insensible or comatose, with stertorous breathing or 
loud snoring ; she cannot be roused by any exertion for some time, 
and if she recover for a moment her scattered senses, she is without 
the slightest recollection of what has passed. This truce is almost 
always of short duration ; convulsion follows convulsion, without our 
being able to determine the period or cause of their return. 

1258. When convulsions attack a woman absolutely in labour, or 
when this is about to take place, we may observe a pretty regular 
occurrence of the fits with the probable return of the pains — for 
though the patient be insensible to external occurrences, she appears 
to manifest by her moans, and the suspension of respiration, her sen- 
sibility to uterine contraction. This appears to me to be so mani- 
fest and decided, that I think I could tell what is going on at the 
mouth of the uterus, without an examination per vaginam. 

1259. The face becomes very much swoln, especially the lips and 
eyelids : indeed, the whole body seems to partake in a greater or less 
degree of this intumescence, but in no part so conspicuously as the 
face. So completely is the countenance changed, or rather disfi- 
gured, that oftentimes it could not be recognised by the dearest or 
most intimate friend ; nor does this swelling immediately subside with 
the convulsions which caused it ; it frequently remains many days after 
they have ceased. Dimness of sight, nay, blindness, for weeks, are 
not unusual consequences of this disease. 

* I do remember to have witnessed the condition of the system mentioned by Dr. 
Lyman ; "oedema, and a remarkable slowness of pulse, as the precursors of convul- 
sions," p. 347. I have often remarked the bloated face after the attack, but never an 
cedemalous condition of the system, previously to it. Not that this condition of the 
system, especially of the lower extremities, is uncommon, but that 1 have never found 
those who were subject to it, more liable to the attack of convulsions than those in 
whose system this condition did not obtain. Indeed, it would seem that they should 
be less obnoxious to it, as this class of females are rarely so plethoric as others, as effu- 
sion in the cellular tissue seems to relieve this over-fulness. 



PUERPERAL CONVULSIONS. 389 

1260. In the apoplectic species* we have nearly all the premoni- 
tory symptoms enumerated above, (1253,) but of much shorter dura- 
tion.! It may, like the epileptic, attack at any period of gestation but 
does not always produce, or be accompanied by labour. From this, 
it would appear it may be brought on by causes independent of preg- 
nane v, though this process may with propriety be regarded as an ex- 
citing cause ; for it sometimes takes place when this process is at its 
height, and labour is "no otherwise accessary to this end, than in- 
creasing by its efforts the determination of blood to the head. This 
species may perhaps with much propriety be considered only an 
exalted degree of the epileptic — in this, the epileptic, there is perhaps 
only engorgement; in the other, there is almost constantly effusion. 

* - The Hysteric species. — This form of the disease usually commences by in- 
voluntary sobbings, (a circumstance I never saw,) or sighing - , yawning and stretch- 
ing of the limbs, by a sense of constriction in the throat, so that the efforts of swal- 
lowing are painful and difficult; by great flatulency in the bowels, and often by a trou- 
blesome incontinence of urine." 

"Tetanic Eclampsia. — The tonic contractions in this species seldom affect the whole 
body, but are usually confined sometimes to one part, sometimes to another, com- 
mencing either in the jaws or in the limbs. The spasms, although the symptoms cer- 
tainly differ from what are called the common, alternating, or clonic convulsive move- 
ments, exhibit distinct movements or distinct remissions ; during this continuance, the 
patient is ordinarily deprived of all consciousness, and she is not, therefore, sensible of 
the agonies of the convulsion. 

f In a case of this species, which fell under my notice some time since, I thought it 
was not accompanied by either as much frothing at the mouth, or with as muchsibila- 
tion, as in the epileptic. Mrs. , aged seventeen, pregnant with her first child, com- 
plained, on the 20th July, 1824, of slight pains resembling labour ; and also a general 
diffused pain, but severest in her limbs; so much so, in these parts, as to render her 
almost incapable of moving them : some fever, though slight. Dr. Shaw, under whose 
care she was, ordered her to be bled and purged. 29th, 3 o'clock, A. M., was attacked 
with labour pains; at first they were slight; but had much increased by the time ihe 
doctor was called. Upon examination, the os uteri was found a little opened ; and at 
8 o'clock, A. M. was attacked with strong convulsions, which were repeated about 
every twenty minutes. She was bled about twenty ounces; convulsions continued to 
recur. At 10 o'clock the same morning, the os uteri was pretty well dilated; and 
from a belief that convulsions were at least maintained by uterine distention and irri- 
tation, Dr. Shaw ruptured the membranes, with a hope of tranquilizing them. 

At this time, I was called in. I found the patient totally insensible to any external 
impressions; nor had she discovered any sensibility after the second fit ; breathing with 
considerable difficulty, and snoring pretty loud. The pulse was full, frequent, and 
hard, and the skin hot. Upon examining per vaginam, the head of the child was 
found at the lower strait, presenting with the posterior fontanelle behind the left fora- 
men ovale, and entirely within the uterus — up to this time, about thirty-five ounces of 
blood were drawn. She was attacked with a fit soon after examination. There was 
something remarkable in the character of her convulsions — her eyes were but little 
agitated ; the pupils much contracted ; her face was but little suffused ; there was 
less frothing ai the mouth, and less sibilation than is usual. 

I applied the forceps, and delivered her in a few minutes without the slightest di!li- 
culty. She remained after this for two hours without a fit; at the expiration of this 
time, they recurred about every half hour, until nine o'clock, P. M., when they ceased, 
but without any amendment in the condition of the patient — she appeared completely 
apoplectic. She continued much in this situation until six o'clock in the evening of 
the 31st, at which time she died. Leave could not be obtained to inspect the body. 
She did not complain of headach until the 29th, and this but a short time before she 
became convulsed. She lost, altogether, eighty. two ounces of blood; was freely 
parged, and once cupped. 

34 



390 PUERPERAL CONVULSIONS. 

1261. In the hysterical species, we have not the same train or 
continuance of the premonitory symptoms. If headach attend, it is 
neither so severe nor so permanent ; there is a ringing in the ears, 
globus hystericus, and palpitation of the heart. The face is much 
less convulsed — less vascillation of the eyes, while the larger muscles 
of the body are much more violently agitated ; the patient, at times 
is very obstreperous ; and the muscles on the posterior part of the 
body are almost always violently contracted ; . so much so that the 
body will sometimes describe an arch backward.* I have considered 
this last circumstance, as strongly marking this species of convulsion. 
The face is much less flushed, than either of the two other species ; 
but never pale, agreeably to my observations, as some have re- 
marked.! 

1262. There is no frothing at the mouth ; and the peculiar sibila- 
ting noise which so strongly characterizes the first and perhaps the 

* There are many formidable cases, some of which I have never seen in the extent 
mentioned by Mr. Velpean — take the following as an example of convulsion of the 
uterus itself. 

»* By far the most important of all the partial puerperal convulsions are those of the 
uterus itself— they may take place either during gestation, at the time of labour, or 
after the delivery of the child. M. Menard says that he has known the pregnant ute- 
rus assume during convulsions the shape of a calabash (a species of gourd;) IVJ. Bau- 
delocque cites a case in which it rose, fell, moved to one side, then to another, with 
most surprising violence. M. Petit assures us that, in the case which he saw, the 
convulsions were so strong, that the uterus seemed every moment to be forced down 
into the vagina, and that he was obliged to support it with his hand, to prevent its 
protrusion ; and M. Pacond in his "Compte rendu de la Maternite de Bourg," 1825, 
relates an example of the womb being affected, with actual movements, and with a 
general violent agitation. The instances we have now recorded are of very rare oc- 
currence ; and it is very generally only during the throes of labour, that the uterus is 
the seat of convulsive movements. 

The part most commonly affected is the inferior third of the body, the cervix of the 
organ ; and accouchers have remarked that the period of labour at which the accident 
usually occurs, is when the head only of the infant has just escaped from the o* uteri, 
while the rest of the body is still within. So strong is the spasmodic constriction, 
in some cases, that when attempts have been made to deliver with forceps, the head 
has actually been torn away from the body ; and Dr. Smellie alludes to a case, in 
which he was obliged to perforate the head and evacuate its contents, before de- 
livery could be effected : M. Menard has related an example, in which the difficulty 
was still greater — the labour had continued for four days, the head had been torn 
away by the repeated traction, and even after this, the accoucheur experienced ex- 
treme difficulty in bringing down the arms; the upper portion of the cervix uteri was 
girt round the thorax, like an iron brace, and it was only after repi ate-1 and fruitless 
efforts that at length the hand could get hold of the feet, to complete the delivery. The 
child proved to be ascitic. 

Soon after the birih of the child, the uterus may be affected with partial or general 
spasm; and indeed, that species of retention of the placenta, which our continental 
brethren designate " le chatonnement" is very commonly the effect of such a condi- 
tion. It has been observed that in such cases, the convulsive movements are usually 
limited to that part, beneath, or nearer to the cervix than the contracted ring ; some- 
times, however, the upper portion is also involved, and the accoucheur is able to detect 
a trembling motion, or " fremissement," of its anterior parieties." 

t Dr. Lyman says, "it is particularly important that we should know how to dis- 
tinguish puerperal convulsions from such as are purely hysterical," p. 351. In this I 
fully agree; and I should have felt grateful, had he added to our knowledge in diag- 
nosis, by observations of his own. He has, however, laid down no marks by which 
we can distinguish one species from the other. 



PUERPERAL CONVULSIONS. 391 

second species, is entirely wanting in this — the patient, after the fit, 
can, for the most part, be roused to attention, or will frequently be- 
come coherent, so soon as she recovers from the fatigue or exhaustion 
occasioned by the violence of her struggles, and though she may lay 
apparently stupid, she will nevertheless sometimes talk, or indistinctly 
mutter. After the convulsion has passed over, she will often open 
her eyes, and vacantly look about ; and then, as if suddenly seized 
by a sense of shame, will sink lower in the bed and attempt to hide 
her head under the clothes. The pulse is much less disturbed, nor 
does it ever acquire that extreme velocity and tenuity it does in the 
other two species, for respiration is never so much in danger of being 
suspended.* 

1263. This species attacks women of delicate and nervous habits ; 
the recovery from it is always more rapid, and never, so far as I have 
observed, leaves any imperfection of vision. 

1264. As nothing is so satisfactory, as regards the application of 
remedies for any disease, as the detail of cases, in which their routine 
is exhibited, I shall make no apology for inserting the following from 
my u Essay on Puerperal Convulsions," See " Essays upon various 
Subjects connected with midwifery." 



Case First. 

Mrs. , a delicate small woman, twenty-three years of age, 

pregnant with her first child, was attacked, on the 16th of November, 
1809, at 8 o'clock, A. M., with epileptic convulsions. I saw her in 
an hour after the attack ; previously to my seeing her,'she had had three 
fits, and a fourth was coming on just as I entered the door. Three 
or four days previously to the attack, she complained of a violent 
jaw or toothach, which was looked upon as rheumatic, and no atten- 
tion was paid to it. On the 15th, that is, the day before her illness, 
she was seized with an extremely acute headach ; and, during the 
night, and just before the onset of the fits, she was violently sick at 
stomach, and vomited a large quantity of thick glairy mucus ; imme- 
diately after this she said she could not see, and was in a few minutes 
more seized with convulsions. She laboured under these violent and 
terrific symptoms in an extreme degree. I instantly bled her from a 
large orifice in the arm ^xxxv. by measure ; this, as I have just said, 
was at 9 o'clock, A. M. Eleven o'clock, had two fits during my ab- 
sence, and was now in the third — bled ^xii. Ordered a strong in- 
fusion of senna as an enema — os tincae a little opened, but rigid. 

* Doctor Lyman says, u every variety of the disease is to bc.regarded as dangerous ; 
for though a patient should appear but slightly injured by the first attack a subsequent 
on may prove suddenly fatal," p. 350, loc. cit. I have never seen death follow the 
hysterical species ; though the convulsions may have been very violent. Nay, female* 
who are subject to this affection, are sometimes occasionally affected with convulsions 
during the whole period of utero-gestation, and this without disturbing its economy — 
the same may be said of constitutional epilepsy. 



392 PUERPERAL CONVULSIONS. 

One o'clock, P. M., had two fits since last visit — injection operated 
— pulse still active — face flushed — very restless and uneasy, arising, 
as I believe, from the pains in the uterus — os tincse rather more di- 
lated — to be bled by cups ^x. Four o'clock. P. M., one fit ; cups 
drew well ; senna operated again two or three times ; very comatose 
— ordered cold applications to the head by means of a large bladder 
partly filled with water and some ice — blisters to the legs. Seven 
o'clock, P. M., no fit since last visit — pulse very active — very rest- 
less, constantly making efforts to get out of bed — (I have considered 
this as a pretty certain sign of labour going on,) — os tineas not 
much more dilated ; took ? x - blood ; senna continued to operate. 
Ten o'clock, P. M., no fit since last visit ; pulse still too active ; took 
Jx. more of blood; cold applications. Seventeenth, Mr. Purnell, 
now Dr. Purnell, one of my pupils, staid all night with the patient. 
He said she had one fit, after which he took 5'x. of blood ; senna con- 
tinued to operate. At ten o'clock, A. M. I saw her ; stupor much less ; 
recognised her friends, and asked some questions ; she did not see 
well, a slight squinting was observable. Seven o'clock, P. M., better, 
pulse less active ; but had three stools since the morning visit. 
Eighteenth, Mr. de la Motha, now Dr. de la Motha, another of my 
pupils, staid with the patient last night. She passed a good night, 
was tranquil and rational ; no return of fits during the night ; two 
stools. Saw her at 10 o'clock, A. M., skin dry and hot, fece a lit- 
tle swelled, but perfectly collected. Eight o^elock, P. M., face more 
swollen, and a little flushed ; much headach, pulse very active ; great 
thirst ; took §x. of blood, much relieved by it ; pulse softened 
and diminished in frequency ; cold applications continued. Nine- 
teenth, passed a good night, free from fever and pain ; no return 
of convulsions ; bowels rather tardy ; ordered senna tea. Continued 
much in this condition until 28th, twelve days from the first attack : 
this morning was seized with brisk labour-pains, and was soon deli- 
vered of a dead child. From the degree of putridity, it is presuma- 
ble the child died early in or before the attack. 

On this case it may be proper to remark, 1st. That the child had 
not been felt to move for several days before the patient was taken 
ill — but this is by no means a certain proof of its death. 2d. Signs 
of labour were manifested on the first day of the illness, but were 
evidently suspended, or at least not progressive, after the second. I 
occasionally examined for several days but found the os tineas so 
rigid, as to preclude the idea of manual assistance ; it was there- 
fore not attempted. 3d. Had manual aid been resorted to, I have 
no hesitation in believing it would have been extremely injurious. 
4th. That the convulsions were controlled ten days before delivery 
took place, although, from the state of the uterus, it was evident it 
would sooner or later take place. 5th. That the attack commenced 
between the seventh and eighth month of pregnancy. The lady's next 
pregnancy was not attended by this untoward accident ; strict atten- 
tion was paid to her during the whole period of gestation. She was 



PUERPERAL CONVULSIONS. 393 

kept on a milk and vegetable diet — her bowels were kept open. She 
was occasionally bled, especially when she complained of headach 
— she took, for several months, three or four doses daily of the tinc- 
ture of foxglove, with I think, evident advantage ; and was at the 
proper time happily delivered of a fine child. In her third preg- 
nancy she attended much less to herself, and was not under medical 
restraint, in consequence of which she was again attacked by con- 
vulsions, and was held very much as above related, with the excep- 
tion that labour was much more rapid. Her fourth pregnancy was 
again fortunate, as she again submitted to medical direction. Her 
fifth pregnancy I have understood was again unfortunate, and attend- 
ed with convulsions like two of the former — I did not see her in 
this last pregnancy, having been absent in the country when it 
happened. 



Case Second. 

Mrs. , aged twenty-six years, pregnant of her first child — a large 

plethoric robust woman, was on the 9th of September 1811, at about five 
o'clock, A. M., taken with labour-pains, and sent for her midwife ; be- 
fore the midwife arrived she was seized with terrible convulsions, and 
I was immediately sent for — the fits were frequently repeated, and 
were from their extreme violence very threatening — her face was im- 
mediately swelled — her eyes fairly protruded from their sockets — Her 
tongue terribly wounded, &c. I instantly bled her from the jugular 
vein more than three pints — examined her, and found labour approach- 
ing — ordered a brisk injection — saw her two hours after — had had se- 
veral severe fits — pulse extremely active — labour advancing — bled her 
twenty ounces — injection repeated — astream ofcold water was poured 
on her head during the interval of the fits — eleven o'clock, A. M., fits 
not so severe, but pretty frequent — pulse still very active — took a 
quart of blood — apparently much relieved — lay quieter — one o'clock, 
P. M., had had two or three fits — very restless — moaned every few 
minutes, desirous of getting from the bed — bled her 5xii. — examined 
and found the head low in the pelvis, and delivered with the forceps 
— she had two or three fits after delivery ; and remained insensible 
to every thing for forty-eight hours. She now began to show some 
signs of returning sensibility — was bled twice in the interval — cold 
w^s applied to the head, and legs blistered — she was purged freely 
nna tea. After this, she gradually recovered her senses. She 
was left completely blind for two weeks ; she then began to see im- 
perfectly, but was six weeks before she could distinctly discern ob- 
jects. It may not be amiss to observe, the child was living. 

This case is remarkable, on account of the severity of the disease, 
and the large quantity of blood that was drawn in the short period 
of a few hours. She lost, in the first six or seven hours of her ill- 
ness, one hundred and twenty ounces of bl«od, and about one hun- 

34* 



394 PUERPERAL CONVULSIONS. 

dred and forty altogether : a quantity that might at first sight startle 
the timid or inexperienced practitioner ; but when he reflects that 
there was a patient labouring under one of the most ferocious com- 
plaints in the whole catalogue of human diseases ; the brain threat- 
ened with immediate destruction ; the patient of prodigiously full 
habit ; one who not only neglected the kindly warning of headach, 
giddiness, and occasionally loss of vision, by not having recourse to 
bleeding — but, contrary to the advice of the midwife, fed freely, 
and remained long costive — what then could avert the threatening 
consequences of this disease, but the most prompt and the most sub- 
duing remedies ? Had not the bleeding been carried to the extent it 
was, I really believe it would have been unavailing. Even as it 
was, it did not prevent temporary blindness. Her second pregnancy 
was not attended with any untoward circumstance. 



Case Third. 

Mrs. — —r-, Nov. 10th, 1797 — pregnant with her second child, and 
in the eighth month, was seized while at the ironing table with ver- 
tigo.* She fell, and was immediately attacked with convulsions. 
I was living near ; and was instantly sent for — I found her labouring 
under the general symptoms of this disease — I bled her from both 
arms at once, and took from each arm nearly, if not quite, a quart 
of -blood. She appeared for a short time much relieved ; that is, the 
convulsions were abated — I examined her, but found no change in 
the os tincse. An, injection was ordered, which operated well — about 
an hour after the bleeding, her pulse rose very much ; her breathing 
was more laborious and stertorous, and some convulsive twitchings 
played over the whole body. She was entirely insensible to all ex- 
ternal impressions — the pupils of the eye were much dilated : fearing 
a violent repetition of the convulsions,,, I again tied up the arms, and 
took about twenty-five ounces more of blood — this seemed again to 
moderate the symptoms — no change in the os tincee. Four o'clock, 
P. M., three hours after the attack, the convulsions were renewed 
with considerable violence — she was let blood to the amount of twen- 
ty ounces: — cold water was poured on the head — she was again more 
tranquil,, but not less comatose, though the breathing was less loud ; 
she had, a copious black stool. Six o?clock, P. M., had had several 
fits, but not as violent as at first — pulse still too active ; took eighteen 
or twenty ounces of blood from the arm-^as the pulse was now 
considerably reduced, applied a pair of blisters to the legs, and sin- 
apisms to the feet. Ten o'clock, no convulsions since last visit, 
breathing freer, but loud-^-swallowed a ljttle water with some diffi- 
culty — passed no water since the attack; introduced the catheter, 

* She had complained all the morningvof -intense headach and several times said she 
could not sec — she was advised to leave oft* work, but would not. 



PUERPERAL CONVULSIONS. 395 

and drew off a large quantity — had two stools — made an effort to 
vomit. Eleventh, six o'clock, A. M., was called to her suddenly, 
as her breathing was becoming more laborious and loud, and face 
more flushed, with some convulsive agitations; pulse rather too 
active ; had ten ounces of blood by cups, and a large blister placed 
between the shoulders. From this time there was no return of con- 
vulsions. She gradually recovered her recollection, but remained 
until some time after her delivery, (which took place at the regular 
time,) and with a living child, with imperfect vision, especially in one 
eye. She was, for many years after this, subject to violent headachs, 
which were relieved constantly by bleeding. She had several chil- 
dren after this attack without convulsions. 



Case Fourth. 

Mrs. , October 1, 1803, had been in labour several hours ; she 

had every appearance of being happily delivered of the fifth child, 
when, during a strong pain, she instantly cried out, " My head, my 
head !" and immediately fell into convulsions. She was under the 
care of another physician, to whose aid I was instantly called by his 
own desire — the convulsions were strong, and very frequently re- 
peated — she was largely bled ; on examination, the child was found 
to be far advanced, and was speedily delivered by the aid of the 
forceps — the convulsions, however, continued in spite of every ex- 
ertion to relieve them, and she died in about three or four hours 
from the attack. Leave was obtained to open the body ; the longi- 
tudinal sinus of the dura mater contained, (by estimate) between 
two and three ounces of blood ; the posterior left ventricle was rilled 
with a bloody serum — the other ventricles appeared sound, as did the 
other parts of the brain — no other part was examined. 



Case Fifth. 

Mrs. , aged 24, pregnant for the first time, was taken in labour 

on the 10th March, 1797 — her labour proceeded regularly, and the 
child's head was at the inferior strait, and every rational expectation 
was entertained of a speedy delivery, when she suddenly cried out 
with pain in her head, and declared she could see no one in the 
room ; these symptoms had continued but a few minutes, when she 
was seized with convulsions — she was under the care of the late Dr. 
Shippen, who requested that I might be sent for, and desired I would 
bring my forceps with me. I found the patient in a strong tit, with 
her face literally as black as a negro — it was agreed she should be 
bled extensively — this was done from the left jugular vein, to the 
amount of nearly two quarts ; it had an immediate effect in tranquil- 
lizing her. I now examined her, and found the head low in the pel- 



396 PUERPERAL CONVULSIONS. 

vis ; I applied the forceps, and delivered her of a dead child. Upon 
examination, it was found there was another child ; the uterus soon 
discovered a disposition to act ; but fearing injury from delay, I im- 
mediately delivered by the feet ; which were the presenting parts ; 
the child was healthy and did well : the mother had no return of fits, 
and she rapidly recovered the use of her health, excepting that of 
her eyesight, which did not return, so as to discern objects, for 
several days ; and her vision was very feeble for several weeks. 



Case Sixth. 

I was called on the 10th of July, 1811, to Mrs. , who was, at 

the moment of my arrival, and had been for a considerable time before, 
in a strong convulsive paroxysm. I found several men diligently 
employed in holding her, and opposing her motions ; she was raised 
in the middle like an arch, while- her feet and head nearly met. She 
was between seven and eight months pregnant, and subject to hys- 
terical affections. — She was thrown into this by some altercation with 
one of her neighbours — cold water was dashed in her face, and she 
was bled to the amount of sixteen ounces. The spasms began to give 
way soon after, and in the course of about fifteen minutes ceased. 
She sighed very deeply, and struck her arms very forcibly against the 
bed, and in a few minutes more, inquired what all these men were 
doing with her. I gave her fifty drops of laudanum, and two tea- 
spoonsful of the tincture of assafoetida in some sweetened water, and 
she had no return of the fit. — She went her full time without a repeti- 
tion of them, and was safely delivered of a healthy child. 

I shall now subjoin two other cases, to show of how much con- 
sequence a proper distinction is, in the treatment of puerperal con- 
vulsions. 



Case Seventh. 

I was called on the 16th of April, 1810, to Mrs. , said to be 

in strong convulsions. I was from home when the messenger arrived, 
but went as soon as it was in my power. When I went into the 

sick chamber, I found Dr. with the patient. He told me "Mrs. 

had been attacked about two hours before with convulsions, and 

was in the ninth month of pregnancy — that, previously to the attack 
of the fits, she had complained of violent pain in the forehead, which 
she told her hushand she could cover with her finger. She had this, 
pain several days, but it was much more intense this morning, and 
was attended with a sensation, as if a piece of black gause was before 
her face. She was stooping for some time over a trunk, m which she 
was arranging some articles, when she was seized, and felon the floor 
in strong convulsions." 



PUERPERAL CONVULSIONS. 397 

She was now lying senseless and without motion on the bed ; she 
breathed very heavily, and snored loudly — her face much swoln and 
of a purple hue — the pulse frequent and small, and the extremities 

cold. I inquired what had been done, and was informed by Dr. 

he had given her, twice, sixty drops of laudanum at a time, and that 
since the last dose she had had no fit, and was, in his opinion, very 
much better, requiring nothing but sleep to restore her. — I told him 
very plainly, that I thought he had mistaken the patient's case, and 
had, in my opinion, sealed her fate by the use of the laudanum. — He 
appeared alarmed, but not altogether convinced. — We did every thing 
that we thought might be useful ; but all exertion was unavailing, and 
the patient died in about three hours.— I could not procure leave to 
open the body. 



Case Eighth. 

About three months after the above event had taken place, viz. on 

the 20th of July, 1810, the same gentleman was called to Mrs. 

labouring under convulsions. I was sent for at his request. Before 
I arrived, he had bled the patient very freely, (40 ounces,) by which 
she was considerably relieved — she was near her full time of gestation. 
From her peculiar motions and breathing, I suspected labour had 
commenced — she was examined, and the os uteri was dilated to about 
the size of a dollar. It was, however, pretty rigid. The convulsions 
returned with considerable forte ; the patient was again bled about 
thirty ounces ; a stimulating injection was thrown up the rectum, which 
operated freely ; the mouth of the uterus was now well dilated ; I 
turned and delivered a living child. Mrs. had one fit after deli- 
ver}', but it was not severe. She recovered her senses and feelings 
on the second day after delivery, and no other inconvenience was 
experienced, except some dimness of sight, and slight headach. 
Several days before the attack of convulsions, she had complained of 
the headach, and that particular sensation of a nail being driven into 
the head, and also an occasional loss of sight. 

The two cases just related form a happy contrast in the mode of 
treatment ; the first case proving so unfortunate, made a strong im- 
pression on the mind of Dr. , who very properly profited by it 

in the second case. He candidly confessed they were as similar as 
any two cases of disease could be, and declared himself much shocked 
at the reflections which the unfortunate case gave rise to. 

In every- case of convulsions, it is but too common for by-standers 
to oppose, by strength, the contractions of the agitated muscles. This 
practice cannot be too severely reprehended ; for it is both injurious 
and unnecessary ; it subjects the patient to severe muscular pains, 
which last for very many days after the fits subside. All that should 
be done in such cases is, to prevent the patient doing herself mischief, 
or to prevent her from throwing herself from the bed ; and as a very 



398 



PUERPERAL CONVULSIONS. 



moderate exertion is sufficient for this purpose, therefore, violence 
should never be employed.* " The tartar emetic treatment will be 
found of the greatest utility in enabling the practitioner, till the os uteri 
is duly dilated. We will give the abridged particulars of one case to 
illustrate the practice recommended by Dr. Collins. A. B. was 
brought to the hospital in labour, having had several convulsive fits 
for days previously ; on admission she was insensible, and was placed 
in bed, when a severe fit came on. She was bled to twenty ounces, 
and two table-spoonsful of a mixture (composed of eight grains tartar 
emetic, forty drops of laudanum and eight ounces of water) were 
given every half hour. The fits returned in quick succession. The 
bleeding was twice repeated, ten grains of calomel were given, the 
antimonial mixture continued, and cold lotion applied to the head. 

Hitherto the os uteri was undilated, but in the course of an hour 
it began to expand, and gradually attained the size of half a crown. 
During this time the patient had several fits, some of which were ex- 
tremely violent ; and before she was delivered the following morning 
with the forceps, she had in all seventeen fits since her admission into 
the hospital. In the intervals of the fits, the patient was incessantly 
tossing about, and seemed insensible to every thing. After the ex- 
pulsion of the placenta, thirty drops of laudanum were given and the 
cold applications kept steadily on the head. During the following 
four hours she had seven fits, but none now occurred, and she re- 
mained in a stupid dozing state. The tartar emetic mixture was re- 
sumed ; but as the unpleasant symptoms did not abate, twelve ounces 
of blood were drawn, and powerful purgatives were administered ; — 
a blister also was put on the nape of the neck. In the course of twelve 
hours, these active remedies had induced a considerable abatement of 
the lethargy and general oppression. For several days the mind was 
always more or less disturbed, and it required repeated application of 
leeches to the temples, and the employment of the most rigid anti- 
phlogistic treatment to lead the case to a favourable issue." — Dr. 
Collins' Practical Observations relating to Midwifery. 

We have subjoined the above quotation, as it promises us with 
another powerful therapeutical remedy. 

* The following- interesting statement of the result of forty three cases of puerperal 
convulsions from Dr. F. H. Ramsbotham's Lectures on Midwifery, is recorded in the 
14th Vol. of the London Medical Gazette. 

" Of forty-three women whom I have seen under puerperal convulsions, in ten cases 
fits attacked the patient before labour pains came on ; in twenty-four, during labour 
itself, and in nine after the birth was perfected. Thirty of these women were delivered 
naturally ; five by the forceps ; three by craniotomy ; four by turning ; and one by the 
blunt hook. Thirty-six recovered perfectly ; seven died ; one was a twin case. Of the 
children, twenty-one were born alive, twenty-three dead. About two cases out of three 
were first pregnancies. Of those that died, in one instance I found a large quantity of 
blood, extravasated under the arachnoid membrane, which had escaped from a rup- 
tured vessel in the pia mater, situated between the convolutions of the posterior lobe 
of the right hemisphere of brain. 

From so large a proportion of recoveries, we are disposed to believe that many of 
these cases must have been of the hysterical species ; as in this city, not more than one* 
perhaps, in three recovers from the first two species. 



INVERSION OF THE UTERUS. 399 



CHAPTER XXIV. 



OF THE INVERSION OF THE UTERUS. 

1265. This untoward, and too fatal accident, is, perhaps, more 
frequent than is commonly supposed. Instances of sudden death 
after delivery often remain unaccounted for ;* and there is every reason 
to believe, that this displacement of the uterus is sometimes the cause. 
Examinations of women who have died during labour, or soon after 
delivery, are not so frequent as their importance seems to de- 
mand. This indifference to examinations after death, arises, 1st, 
from an inadequate estimate of their value, even by medical practi- 
tioners ; 2dly, from the aversion most people feel to have their friends 7 
remains disturbed ; 3dly, to the disingenuous conduct of the attend- 
ing physician himself, who may not wish the cause of death to be as- 
certained, lest it should do injury to his character, either from his not 
having known or suspected the true one, or by exposing some lesion 
for which he fears the world would hold him accountable, though he 
had no agency, either directly or indirectly, 'in producing the accident 
by which death has been produced. Hence, as I have just observed, 
this complaint is, most probably, every now and then concealed ; 
and, therefore, the frequency of the inversion of the uterus in pro- 
ducing death, cannot be exactly estimated. 

1266. Inversions of the uterus may be either complete, or incom- 
plete — by a complete inversion, I mean the passing of the fundus 
and body of the uterus through the os externum, or being turned en- 
tirely inside out, to the very mouth of this organ ; when this takes 
place the mouth of the uterus is looking upwards, and is within the 
cavity of the abdomen. But it is not necessary to the complete inver- 
sion, that the body and fundus escape through the os externum : 
as this condition may happen, and yet the uterus tfe concealed with- 
in the vagina. 

1267. Air. Burns says, when the inversion is complete, the fundus 
is "protruded out of the vagina." This is not essential to the de- 
finition ; since I have known the uterine tumour to pass through the 

* Levret in his chapter, " sur la cause la plus ordinaire, dela mort subite, &c. tree 
peu de temps apres Paccoi»chment," attributes the greater part of such deaths to the 
want o f ' contractile power in the uterus, thereby giving rise to fatal hemorrhages. He 
does not appear to have been aware, that the partial inversion may be a cause of death, 
or in some instances contribute to it, as he passes without notice this circumstance in 
the case he quotes from Mauriceau ; who says, on opening the body, nous trouvames 
le fond de la matrice un peu de prime encedans, comme est le cul d'unc fiolledc verre, 
au lieu d'avoir une figure rond, comme on le voit ordinairement." Obs. 230. While 
Ant. Patit thought the " inversion of the uterus to be impossible : and declared that ihose 
authors who mentioned this condition of the uterus, had mistaken a polypus attended 
by a prolapsus of the vagina for it. 



400 INVERSION OF THE UTERUS. 

os externum, without entirely inverting the neck to the mouth ; and 
again, I have known the inversion to be complete, and the fundus 
not escape from the vagina. 

1268. The incomplete, is where neither the body nor fundus have 
entirely escaped through the os uteri, and may be in different degrees; 
1st, the simple depression, or where the fundus falls down to the 
mouth of the uterus; but is prevented from passing through it, by the 
latter being contracted ; or the force may have been insufficient for 
this purpose ; 2dly, where it has passed perhaps half its length 
through the os uteri ; 3dly, where it is completely inverted, with the 
exception of a portion of the body and neck. We could wish this 
definition to be remembered. In the two latter conditions, the body 
and fundus may be compressed or strangulated, by the neck of the 
uterus contracting forcibly upon the protruded part ; or it may be 
free from this restraint : each of these presents different indications. 

1269. Remote cause. — The remote cause of this accident is, the 
want of power or disposition, in the body and neck of the uterus, to 
contract. This may be occasioned by an over-distention of this or- 
gan, from an excess of liquor amnii ; from the unusual size of the 
foetus ; from a compound pregnancy ; from hemorrhagy ; "from pas- 
sions or emotions of the mind ; from exhaustion, in consequence of 
previous disease ; from long continued uterine efforts to effect de- 
livery, &c. 

1270. Proximate cause. — For the uterus to become completely in- 
verted several circumstances must combine ; first the fundus must 
most probably contract, while the body and neck must be flaccid ; 
secondly, a force or weight must be applied to. the fundus, which is 
capable of making it descend through the os internum ; this force may 
be a power applied to the cord ; and the weight may be the placenta 
itself, when it is ingrafted immediately upon the fundus, or the pres- 
sure of the abdominal viscera, &c. But let it be remembered, that 
in the incomplete, the mouth of the uterus looks downwards, or into 
the vagina, and is always within the vaginal portion of the pelvis, 
though completely filed by the descending portion of the body of the 
uterus. See par. 1266. Plates XIV., XV., XVI., XVII. 

1271. Symptoms. — When this accident takes place, the woman 
almost instantly complains of a severe and distressing pain about the 
region of the uterus ; an effort to force or bear down ; nausea, and 
sometimes vomiting; great faintness, with more or less hemorrhage ; 
cold clammy sweats ; pulse small, frequent, or extinct. A variety of 
nervous symptoms may also occur of a most distressing kind, arising, 
most probably, from the new situation the abdominal viscera are 
forced to take, when deprived of the support of the uterus. 

1272. If we examine per vaginam, it will be found that the vagina 
is occupied by a firm resisting tumour, covered by the placenta, or 
otherwise, as the period may be at which this accident occurs ; or the 
fundus and body may be pushed through the os externum, either 
bare or covered by the placenta. This casualty may take place im- 



INVERSION OF THE UTERUS. 401 

mepiately after the* birth of the child; or it may not occur for hours, 
or even days, after this event.* If the hand be now placed upon 
the abdomen, we shall fail to find the uterus. 

1273. Incomplete. — The incomplete must have the same general 
causes as regards the effect upon the fundus and body — that is, the 
fundus cannot be supported by the body, from its loss of power, by 
the operation of either of the same remote causes, (1270;) but is pre- 
vented from entirely passing through the neck, by the latter contract- 
ing, and arresting it within, or only permitting it to pass in part. 
The same general train of symptoms occurs, but this condition is al- 
most always attended with a greater discharge of blood, than when 
the inversion is complete.! If an examination be carefully made 
per vagi nam, the fundus of the uterus may be detected in one of the 
situations mentioned for this species or varieties of inversion, 
(126S.) 

1274. The incomplete inversion, we have observed, has various 
degrees of derangement ; name!}-, from the simple depression, (1268,) 
to the entire escape of the inverted body and fundus through the os 
uteri of the uterus; but they are not equally distressing or dangerous, 
though neither condition is free from risk. Thus, the simple depres- 
sion is not necessarily as fatal as when the fundus alone has passed 
through the os uteri ; and the latter not so full of danger, as when the 
inversion more nearly approaches to being complete. Perhaps mere 
depression, unaccompanied by hemorrhage, might not be absolutely 
fatal ; but as there can be no possible security against this condition, 
longer than the placenta preserves its entire connexion with the uterus, 
it must be regarded as a case of possible, nay, of probable danger : 
and consequently, should never be trusted after it is detected. 

1275. The symptoms, however, in each of these degrees of inver- 
sion, differ only in intensity ; for all are marked by a peculiarity of 
suffering, the force of which will very much depend upon the extent 
of the displacement of the fundus and body of the uterus, and the 
constricting force of the os uteri through which they may have passed. 
For instance ; the simple depression will be marked by less suffering, 

* A very remarkable case of" complete inversion" taking place a long time sub- 
sequently to labour, is given with great clearness and accuracy, by Mr. Watkinson, in 
Med. and Phys. Jour. Vol. VII. p. 433. This case wasof long duration, and eventually 
and suddenly fatal, after i' had been amputated bv cutting through the prolapsed and 
inverted vigina. Mr. W. assigns as the cause of death, the relaxed state of the os 
uteri; and perhaps of the uterus itself, occasioned by the long protracted hemorrhage, 
and the formation of coagula; in expelling the latter, the uterus was perhaps in- 
verted. 

t It is a remarkable fact, that less blood is lost when the uterus is completely than 
when it is partially, inverted. This is not, perhaps, of difficult explanation; since 
when the inversion is complete, the uterus contracts to a certain extent; and by this 
contraction, the now internal surface of this organ is made to impinge upon the ves- 
sel* which carry blood to it, and thus interrupts or.cuts off fresh supplies of this fluid. 
It may also be proper to observe, that hemorrhage is never so suddenly alarming, in 
cases of inversion, as it is when it arises from the uterus being in a state of atony, and 
the placenta detached from it 

35 



402 INVERSION OF THE UTERUS. 

than when the fundus has passed the mouth of the uterus ; and the 
alarming symptoms in the last case, will be in proportion to the con- 
traction of the os uteri: if this be feeble, the risk, and sufferings, will 
be comparatively moderate ; but when the stricture is very severe, they 
are not only of the most distressing kind, but highly dangerous. Yet 
each of these conditions may accidentally be equally dangerous though 
not equally alarming in the intensity of their symptoms. Thus, the 
simple depression, may be as fatal as a more extensive displacement, 
in consequence of the profuseness of the flooding W T hich may attend 
it, though the sufferings of the patient may be much less severe than 
when the inversion is more extensive. (See Case I.) 

1276. The mechanism of inversion is sufficiently simple ; it seems 
to require but a state of atony of the uterus to produce it, with, per- 
haps, more or less pressure upon the fundus of this organ ; or, possi- 
bly, the mere contraction of the fundus, and the implantation of the 
placenta on this part. When this derangement takes place before the 
delivery of the after-birth, we have much reason to suspect that its 
weight, as well as its location, materially contribute to its production 
— this location of the placenta, indeed, seems to be almost a sine qua 
non to inversion ; for we either find the placenta discharged from the 
vagina, or else attached to the fundus of this organ : now T , had the 
placenta been attached to any portion of the body of the uterus, that 
part must have contracted that it might be thrown off; and that con- 
traction of the body of the uterus, most probably, would have given 
such support to the fundus as to have prevented its falling down. 

1277. It is almost universally believed, that an undue force applied 
to the cord for the delivery of the placenta, is the principal cause of 
this accident ; but in this I differ, from such as have adopted this opi- 
nion ; and for the following reasons : first, because the accident has 
occurred after the delivery of the placenta ; secondly, because it hag 
taken place, when no such force has been applied.* But the caution, 
not to apply much force to the cord to deliver the placenta, is founded 
upon just and important principles; since, did the disposition to in- 
version exist, and this mass be attached to the fundus, it would be 
almost certain to produce it ; whereas, perhaps, without such force, 
the woman might escape from the danger. 

1278. Mr. Burns, after enumerating several causes of inversion, 
such as pulling of the cord ; the too sudden delivery of the child when 
the cord is too short, &c, says, "from the same cause, or sometimes 
perhaps, from sudden pressure of part of the intestines on the fundus 
uteri, occasioned by strong contraction of the abdominal muscles, a 
part of the fundus becomes depressed like a cup, and encroaches on 
the uterine cavity. This generally rectifies itself if left alone." I 
would inquire, for the sake of information, how this dipping of the 

* In eviderrce of this, Mr. Welsh says, in his account of a case of inversion, that, " on 
dividing the funis to remove the child, I was extremely surprised to find the uterus 
completely inverted, and lying without the labia, on the thigh." — Lond. Med.andPhys. 
Journal, Vol. V. p. 451. 



INVERSION OF THE UTERUS. 403 

fundus is known to exist ? and how it is ascertained, that it " generally 
rectifies itself if left alone?" 

1279. I can readily comprehend, that an unusually short cord, with 
the sudden expulsion of the child, may produce inversion, even when 
there is no disposition to atony in the uterus ; as the fundus may be 
dragged down at the instant relaxation is about to take place ; but I 
confess myself entirely at a loss to comprehend what Dr. Merriman 
(Denman's Midwifery* Francis's ed. p. 514) may mean by a short 
cord, when its length permitted a child, by a sudden effort of the 
uterus, to be "thrown to the extremity of the bed," though this cord 
was " naturally short, besides being twice passed round the child's 
neck," and the placenta retained, "though low in the pelvis." 
Quere, if this be a short cord, what constitutes a long one ? 

1:280. The indications in inversion are simply these : first, to restore 
the prolapsed fundus when practicable ; secondly, to prevent a rein- 
version after restoration ; and thirdly, if the fundus cannot be restored, 
to prevent death by taking off the constriction occasioned by the con- 
traction of the mouth of the uterus. 

1281. When the fundus is prolapsed to the mouth of the uterus, 
but contained within it, should the mouth of the uterus be sufficiently 
yielding, the hand must be gradually passed through it, and the fundus 
carried upward until restored — if the placenta has been thrown off, we 
need but retain the hand within the uterine cavity, until we have suffi- 
cient evidence of its disposition to contract, and to maintain that con- 
traction. If the placenta has not been thrown off, it will be found 
either loose or adherent — if loose, it must be withdrawn with the 
hand, after we are satisfied that we may trust the uterus to itself. If 
adherent, we must gently separate it after the uterus shows signs of 
returning power, and when separated, it must be taken from the uterus, 
when the hand is retracted. It is more than possible that the mouth 
of the uterus may contract so firmly in this species of inversion, as to 
prevent the introduction of the hand to restore it. In this case, shall 
we act upon the hope that this case u generally rectifies itself if let 
alone," or shall we attempt the restoration of the fundus by some safe 
mechanical contrivance ? Might not a stiff piece of whalebone, or 
tough wood, armed by a piece of rag, be employed with a prospect 
of success ? for we must ever deprecate violence to the mouth of the 
uterus. 

1282. Should the fundus have escaped in part through the mouth 
of the uterus, it should be as quickly as possible returned, by pressing 
the most depending and central portion of the tumour gently, steadily, 
and perseveringly in the direction of the axis of the os uteri until it 
retire ; then if it do not return to its proper situation by its own resi- 
liency, we must pursue it with the hand through the mouth of the 
uterus, nor should it be left unsupported until placed in situ. And 
the hand must be kept in the uterus, until, by the contraction of the 
uterus, there is assurance it may be withdrawn with safety. 

J 283. We now and then meet with cases in which the relaters 



404 INVERSION OF THE UTERUS. 

would seem to persuade us that some special providence had inter- 
fered to save their patients, since they record departures in the animal 
economy that can be accounted for upon no other principle. Now, 
nothing is more to be dreaded than the atony of the uterus after deli- 
very: we have already declared it to be (1270) one of the remote 
causes of the " inversion of the uterus ;" and every body acknowledges 
it to be the reason why hemorrhage takes place after delivery, when 
the placenta is separated, either partially or altogether. Yet we find 
mention of a case of inversion by Dr. Loffler, in which the fundus of 
the uterus could not be retained after reposition, owing to the loss of 
tonic power of this organ, but again and again descended through the 
os uteri.—" The fundus uteri having receded through the orifice of 
the uterus, I pursued it with my hand, which J kept in the uterus, waiting 
for the contraction of this organ. But after I had continued in this 
position about half an hour without perceiving any contraction, I was 
obliged to withdraw my hand, when the fundus immediately de- 
scended, but was prevented from passing through the orifice." A 
variety of things were done for twelve hours to promote the contrac- 
tion of the uterus, as stimulating injections into its cavity, frictions, 
&c.j but all to no purpose ; for the uterus remained in the same flaccid 
state, and he was at last under the necessity of propping up the fundus 
by a tube made of horn. This was effected without much difficulty ; 
the lochia passed off properly, &c, and the woman recovered. Now, 
this case is altogether a miracle ! — a woman had an uncontracted 
uterus ; a separated placenta ; and yet there was no hemorrhage ! ! ! — 
at least no mention is made of any, though the uterus remained days 
uncontracted. (Med. and Phys. Journ. Vol. II. p. 207.) 

1284. If the placenta offer itself before the prolapsed fundus, we 
may, if detached, deliver it immediately ; but if it be adherent, and 
the mouth of the uterus does not offer too much resistance, it must be 
carried up with the fundus, and separated as before directed, (1281.) 
Should we, however, find much opposition to reduction, and this 
evidently, in part, arising from the bulk of the mass to be restored, it 
will, perhaps,* be best to separate it carefully, and then carry up the 
fundus. 

1285. Should the inversion be complete, it will for the most part 
be impossible to restore ife > -f especially if several hours should have 
elapsed after the accident. Dr. Denman says, " the impossibility of 
replacing it, if not done soon after the accident, has been proved in 
several instances, to which I have been called, so early as within four 
hours, and the difficulty will be increased at the expiration of a longer 

* I say " perhaps," because I cannot speak more'positively upon a subject on which 
my experience is so limited. The propriety of this practice I wish to leave for farther 
observation ; for having met with but four cases of "inversion,"* 1 think that number 
inadequate to establish the best mode of practice. 

f I would not dare to say, it would be impossible to restore the uterus after its com- 
plete inversion ; though I believe it, at this moment. 

* Since the above period I have seen several more cases of inversion. See note to par. 1301. 



INVERSION OF THE UTERUS. 405 

time. Whenever an opinion is asked, or assistance required in those 
cases which may not improperly be called chronic inversions, it is 
almost of course that the reposition should be attempted ; but I have 
never succeeded in any one instance, though the trials were made with 
all the force I dare exert, and with whatever skill and ingenuity I 
possessed ; and I remember the same complaint being made by the 
late doctors Hunter and Ford ; so that a reposition of a uterus which 
has been long inverted may be concluded to be impossible. It seems 
as if the cervix of the uterus continued to act, or had soon acted in 
such a manner as to gird the inverted uterus so firmly, that it could 
not be moved." This account of the impracticability of restoring the 
fundus when the inversion is complete, is in strict conformity with 
my own experience. 

12S6. It is true, it is said that the uterus has been reinstated after 
44 complete inversion ;" but of this we may justly entertain doubts ; 
for the one recorded by Mr. White purporting to be of this kind, was 
certainly not one of " complete inversion." In Mr. White's patient, 
we recognise nothing more than a partial one, as the symptoms de- 
clare. 5lr. W. says he saw the patient about an hour after the acci- 
dent, and " found the uterus of the size of a large new-born infant's 
head totally inverted." Yet he declares the woman "was in great 
pain, and had lost much blood ;" neither of which circumstances 
attends complete inversion ; for it seems to be agreed, that there is 
not much hemorrhage at this time, and I know that pain immediately 
ceases, when it becomes complete, as I shall state presently. 

1287. This patient " was very faint, and no pulse could be felt in 
either arm :" a condition which constantly attends the partial inver- 
sion ; especially when the mouth of the uterus contracts firmly upon 
the body, producing a strangulation of the uterus; which was pre- 
cisely the situation of Mr. W's. patient ; for he declares u the neck 
was a little contracted." Now, it must be obvious, upon a moment's 
reflection, that if the inversion were complete, the mouth of the ute- 
rus cannot be felt ; for this part now offers its opening to the cavity 
of the abdomen, and is not tangible by the finger. See case second, 
and Plate XVI. 

1288. There is a condition of the partial inversion, where it is as 
certainly impossible to restore the fundus, as if the inversion were 
complete ; and this is, where the fundus and a part of the body have 
passed the os uteri, and the latter contracts, " so as," as Dr. Denman 
expresses it, " to gird the inverted uterus firmly, so that it cannot be 
moved." When this happens, the stricture occasioned by the con- 
tracted mouth, is so firm and resisting, that a finger cannot be passed 
between its edge and the confined uterus — in this case, I believe it to 
be impossible to pass the fundus, as the constriction would not yield 
to any force we could use with safety. 

1289. This variety of partial inversion, produces the most terrible 
and alarming symptoms imaginable ; pain, faintness, vomiting, deli- 
rium, cold sweats, extinct pulse, convulsions, and, if not speedily 

35* 



406 INVERSION OF THE UTERUS. 

relieved, death. Under such sufferings, when all hope of restoration 
is at an end, I have advised, with a view to terminate them, and to 
preserve life, that the fundus and body should be drawn still farthei 
down, so as to complete the inversion. Should the placenta be 
attached, it must be carefully separated before we draw down the 
fundus. 

1290. The propriety and safety of this plan, are, it must be con- 
fessed, predicated upon the happy result of a solitary case ; but, from 
its entire and speedy success in this instance, it is rendered more than 
probable that it will be of equal advantage, if employed in others." 
u All reasoning upon the subject," is certainly in its favour; and 
experience, so far as a single case may be entitled such, is equally 
so. See note to par. 1301. 

1291. Should the practitioner, however, be so fortunate as to meet 
with a case where the mouth does not confine the protruded part, he 
should attempt restoration, however large a portion of the uterus may 
have passed through the os uteri, by gently, but firmly compressing it, 
so as to reduce its size ; having first removed the placenta, if not pre- 
viously done, and urging the prolapsed part upward in the axis of the 
os uteri. In such a case, perseverance may, I am willing to admit, 
do much, and it ought most certainly be tried if there be the smallest 
chance of success. 

1292. The chance, however, should be clearly ascertained, by 
carefully examining the condition of the constricting part — if it be 
soft and yielding, a hope may be indulged that the resistance may, 
by proper proceeding, be overcome. If this friendly condition ob- 
tain, there will be, beside this pliant disposition of the os uteri, an 
absence from all, or nearly all the terrible symptoms just enumerated, 
(1289 ;) but if he cannot find the mouth of the uterus by a careful 
examination after the placenta is removed, and if there should be an 
absence of the train of appalling symptoms above named, he should 
desist at once from every attempt at reduction, as his efforts will not 
be attended by success ; and the continuance of them will not only 
give his unhappy patient much unnecessary pain, but will hasten her 
death. 

1293. The mode to be pursued, when it is necessary to complete 
the inversion,, is simply to place the woman upon her back near the 
edge of the bed ; and have her legs supported by proper assistants 
— the hand is to be introduced along the inferior part of the vagina, 
but sufficiently high to seize the uterus pretty firmly ; it is then to 
be drawn gently and steadily downward and outward, until the in- 
version is completed ; this will be known by a kind of jerk 
anouncing the passing of the confined part through the stricture. 
Traction should now cease,, and the part be carefully examined ; if 
the inversion be complete, the mouth of the uterus will no longer 
be felt, and there will be an immediate cessation of pain, and other 
distressing sensations. 

1^94. The proposal just made, "to convert an incomplete in- 



INVERSION OF THE UTERUS. 407 

version into a complete one," in cases in which it is deemed 
impossible to place the fundus in situ, is either an important im- 
provement in the treatment of this complaint, or is a most mis- 
chievous direction ; it, therefore not only merits, but absolutely 
requires a dispassionate, and candid examinntion. In inquiring into 
the merits of this case, I shall lay aside every feeling of self-love 
that might reasonably be supposed I would cherish, as the author 
of an original, and, perhaps, a highly important suggestion ; and I 
will, also, as far as either my experience, or my reading shall ena- 
ble me, give the subject a temperate, and liberal consideration. 

1295. In this investigation, I will first inquire into the nature of 
the case, which is supposed to require this operation ; secondly, 
determine the situation, and condition of the parts, after the inver- 
sion is complete ; and, thirdly, investigate the cases which purport 
to be cases of complete inversion, and in which the uterus is said to 
have been restored to its natural situation. 

1296. I. It has been alvvavs found, when the greater bulk of the 
uterus has passed the os uteri, that the most alarming symptoms 
immediately ensue ; and if the parts be not speedily relieved from 
this unnatural situation, the case will almost constantly terminate in 
death. (See case first.) The terrible symptoms just spoken of, 
arise from that portion of the uterus, which is below the circle of 
the os uteri, becoming strangulated by the firm and obstinate con- 
traction of the neck, by which it is now surrounded, to say nothing 
of the new situation of this organ — namely, its internal surface 
forced to become the external. Every body conversant with the 
anatomy of the uterus after parturition, will acknowledge, that the 
portion of the uterus which passes through the mouth, in a case of 
inversion, is vastly greater than that portion which constitutes the 
neck ; especially when the latter has a disposition to contract by 
virtue of its tonic power. Now, this contraction must take place 
before the threatning symptoms can show themselves ; consequently, 
the part which is protruded must very much exceed in size that 
through which it has escaped. For the body and fundus of the uterus 
even in the natural relation of these parts to each other, are much 
larger than the neck of this organ ; and when they are newly freed 
of their contents, and are fully engorged with blood, those propor- 
tions are increased; and such is the disposition of the neck of the 
uterus to contract, that in most instances, it is found to be small 
and resisting, very soon after delivery; while the body and fundus, 
though in the healthy exercise of their powers, remain for a long 
time comparatively large. It must, therefore, follow, that unless 
the bulk of the body and fundus can be reduced to the size of the 
constricting circle of the os uteri, or the constricting circle be en- 
larged to a dimension equal to that of the body and fundus, one 
cannot be made to pass through the other. 

1297. II. The situation and condition of the parts, after the inver- 
sion is complete, is very different from what they were before this 



408 INVERSION OF THE UTERUS. 

had taken place. These changes consists, 1st. In the entire removal 
of the constriction, in consequence of the neck of the uterus itself be- 
coming also inverted ; and, consequently, every portion of the body 
and fundus being removed below or over its grasp. 2d. By the 
capacity of the os uteri being still more diminished; as it is no 
longer distended by a portion of the body of this organ ; conse- 
quently, the body and fundus are increased in size, if not positively, 
certainly relatively, while the capacity of the mouth is diminished ; 
as the latter naturally becomes smaller than the former. The uterus 
will now resemble a pear suspended by its stem ; (see Plate XVII.) 
and the relative proportion between its extremities is pretty much 
in the same degree, as that which exists between the two extremi- 
ties of a pear. 

1298. The uterus in a state of complete inversion, is suspended 
by the upper portions of the vagina, and can be pushed a conside- 
rable distance upwards into the pelvis, if we press its fundus in that 
direction ; or, by a contrary force, it may be dragged to some dis- 
tance beyond the os externum ; consequently, it is capable of con- 
siderable motion. 

1299. Now, in order that the body and fundus may be restored 
after inversion, they must return through the contracted mouth of 
the neck of the uterus; and with a view to explain the nature of 
the difficulty that must be encountered in the attempt to perform 
this operation, let us take an example from a suspended, pear-shaped 
gum elastic bottle ; and the material, by which it is suspended, 
capable of bearing but a limited degree of force* Let us imagine, 
however, in our example, that we wish either to produce its*inver- 
sion, or to restore it, after it has been inverted. If we adopt the 
latter, (for it is more analogous,) we must take for granted, that the 
neck, from some cause or other, had lost its power of resistance, 
and had permitted the fundus and body to pass through it ; and that 
now, it is our design to restore them ;: but at a time when the neck 
has recovered its powers, and is now in a state of contraction, or 
resistance. I will ask any man of candour, if, under such circum- 
stances, he would think it possible to restore the fundus and body ; 
(if we may so term the two portions of the gum elastic bottle,) we 
are well pursuaded that he will not, and for the following reasons : 
1st. Because the neck of the oterus, or of the bottle, if we pursue 
the example, is now nearly, or quite at its minimum size, while the 
body and fundus preserve a greater size than natural ; and conse- 
quently, are much larger than the neck. 

1300. 2d. Because there is too great a disproportion between the 
size of the body to be passed and the opening which is to permit it 
to do so, if the natural relation of the parts exist, which in this in- 
stance must be admitted. 

1301. 3d. Because, though it might be possible to make the 
mouth of the uterus yield, by a sufficient force being directly applied 
to it, yet we cannot in this case take advantage of this probability y 



INVERSION OF THE UTERUS. 409 

since our force can only be applied in one way, and that way an im- 
perfect one; namely, by urging the fundus towards the constriction, 
and attempting to make it pass the contracted mouth of the uterus. 
But in this consists one of the difficulties of the operation; for, be 
the body and fundus of the uterus either firmly contracted, or com- 
paratively flaccid, great difficulty would be experienced in pressing 
the centre of the fundus towards the axis of the mouth, if it be even 
practicable.* 

1302. 4th. Because if the fundus be thus carried to the mouth of 
the uterus, it cannot be made to pass, from the excess of its bulk, 
and the resistance of the contracted mouth, unless a force be em- 
ployed that shall overcome all opposition ; and if this be applied, the 
vagina at its union with the neck of the uterus will yield sooner than 
the mouth of the uterus. 

1303. 5th. Because Drs.Denman, Hunter, and Ford, have (1285.) 
all confessed they failed in every attempt they had made to re- 
store the fundus in a complete inversion ; and I will most candidly 
add, that the same failure has attended my exertions, after the 
best directed, and the most persevering endeavours, I could devise. 

1304. 6th. Because no pressure or force, however well-directed, 
however long-continued, can diminish the fundus and body, below 
the natural size of the mouth of the uterus, when this is in a state of 
contraction. 

* In two cases of inversion, one complete and the other nearly so, I persevered in 
the attempt at reduction, nearly two hours. The plan I pursued, in both, and I be- 
lieve it is the only one which promises success, was, after grasping the bulk of the 
protruded part firmly, but gently, for half an hour, with the intention of dispossessing 
it as much as possible of blood, and thereby reducing its bulk, I then placed the ball 
of my thumb to the centre of the fundus, and gently and steadily pressed it in the di- 
rection of the axis of the mouth. After continuing this pressure for a Ion? time, I 
found my thumb buried in an indentation of about an inch in depth, which encouraged 
me to persevere a considerable time in the same kind of force. Atone time I thought 
my efforts were about to he crowned by success, as I believed I was making the fun- 
dus encroach upon the circle through which it must pass, before it could be reduced. 
But I was too soon convinced my hopes were delusive, for upon an accurate examina- 
tion of my proceedings, I found my supposed progress was altogether owing to the 
straining of the os uteri at its connexion with the vagina ; and I was obliged to abandon 
an enterprise that at one moment I had flattered myself was about to be successful, 
as my patient's strength was fast wearing away. The only remaining chance, as T 
believed, was to complete the inversion ; this I did without difficulty. It afforded re- 
lief; but the patient was too much exhausted for to profit by it, she died thirty -six 
hours after. It may be proper to mention that when I first saw this patient, she was 
nearly exhausted by hemorrhage and suffering, and almost pulseless. After com- 
pleting the inversion, she seemed to improve, as a moderate reaction took place; but it 
was snort lived ; she sank after this time not to be again roused. The other case which 
happened within a short time, (April, 1827,) the patient was not much exhausted; as 
the midwife r.ccame early alarmed, and I was sent for soon after the accident. I have 
reason to believe the midwife completed the inversion by dragging at the placenta, 
which brought the fundus of the uterus through the os externum. This was reduced 
after a few minutes, by gently and firmly pressing it upwards in the direction of the 
vagina. I persevered in this case, as industriously and as steadily as in the other, 
and with no better success. This woman labours under a considerable bloody dis- 
charge, but which is gradually diminishing; and is* recovering strength slowly.* 

* I have seen this patient within a few days, (Oct. Ii27) She has nearly recovered her usual 
strength, but is still pale and sickly in look. 



410 



INVERSION OF THE UTERUS. 



1305. III. I shall now examine such cases as purport to be in- 
stances of reduction, after " complete inversion." From what T have 
already said upon this subject, it will be seen, that a very indistinct 
notion has been entertained of the complete " inversion of the 
uterus ;" and if our definition be referred to, (1266,) and admitted, 
as it certainly should be, I think it will be easily shown, that na one 
instance in which it is said re-inversion was effected, was a case of 
complete inversion."* 

1306. We have already given our reasons for not allowing Mr. 
White's case to have been one of " complete inversion of the uterus," 
(1286,) and the same argument will apply to all such as purport to 
be of this kind, as far as I have had it in my power to examine them. 
Thus, we find a case stated in the " New England Journal," Vol. I. 
third series, p. 264, which is called a case of complete inversion, 
and in which reduction was effected. The relater says, " The at- 
tending physician pulled gently at the cord ; immediately the placenta 
pushed forward, protruded at the external orifice, and was followed 
by the uterus, completely inverted. The placenta still adhering, he 
separated it with the fingers, and returned the organ, as he supposed, 
into its proper placed On Saturday, (the day after the delivery,) the 
patient was taken out of bed, when the uterus immediately protruded 
out of the body, followed by a copious discharge of blood. Dr. 

was in a few minutes called in, and pushed the protruded uterus 

within the vagina, -supposing that this was all that was necessary 
to be done, or rather concluding he had returned the prolapsed part 
into its original situation. The loss of blood was considerable, so much 
so as to produce syncope, from which she was gradually restored by 
cordials, friction, and volatiles. A moderate discharge still con- 
tinued to flow till about twelve o'clock at night, when the pulse began 
to sink, accompanied with faintness and great prostration of strength." 
"Upon examination," says the relater, " I found the uterus completely 
inverted, occupying the whole of the vagina, the neck reaching above 
the pubis." He then declares, the fundus, by proper manipulation, 
was restored. This case, however, proved eventually fatal. 

1307. This case, we may safely declare, was not one of" complete 
inversion" of the uterus ; and for the following reasons : — First, 
because the phenomena were not those which accompany a complete 
inversion ; there was too much hemorrhage, and too many distressing 
symptoms. :f Secondly, because the author expressly and conclu- 
sively determines this point, by saying, " the neck of the uterus reached 

* Mr. Newhara makes the absence of the neck surrounding the prolapsed part es- 
sential to a complete inversion. 

t We presume he intends to be understood, by the words " returned the organ into 
its proper place," that he restored the protruded body and fundus to their natural situa- 
tions. 

t "But it is worthy of notice that, frequently, complete inversion is not accompa- 
nied with hemorrhage." Burns, p. 516. This obtained in Dr. Hamilton's case, and 
this is agreeable to the observations of others. In Dr. Denman's case II., which was 
a case of complete inversion, he says " the hemorrhage was not profuse." 



INVERSION OF THE UTERUS. 411 

above the pubis." I have already pointed out the situation of the 
mouth and neck of the uterus in the complete and incomplete inver- 
sion of the uterus, in par. 1285. 

1308. In a review of my " Essays on various subjects connected 
with Midwifery," by a writer in Vol. III. No II. p. 157, of the third 
series of the new England Journal, &c, I find the following observa- 
tions in reference to my proposal of converting a partial inversion 
into a complete inversion, when there is no chance of restoring it, 
and the symptoms are threatening. " The practice in this case," 
(case second,) "was successful in rescuing the patient from imminent 
danger. It left her the subject of inverted uterus the remainder of life. 
This last fact makes the question of adopting Dr. D's. method a very 
serious one, and in considering this question we are met by others. 
Is there no cliance of reducing the uterus after the stricture has been re- 
moved in the manner proposed above, and should its reduction be at- 
tempted either immediately after or as soon as the patient is enough re- 
cruited to endure the fatigue and pain of a trial ?■ A case has been 
related to us of at least two days standing, in which the physician, 
having grasped the uterine tumour in his hand, gradually compressed 
it, and after a long continued effort, succeeded in reducing this organ. 
This was related by the physician who performed the operation. The 
inversion here was complete, and this may make such a difference be- 
tween the cases as to render it questionable whether similar means 
would be applicable to both." 

1309. This critique involves a number of separate propositions, 
which we shall notice in their order. First, " It left her, ^the patient,) 
" the subject of inverted uterus for the remainder of life." The 
question which presents itself to meet this objection is simply, whether 
an accoucheur is not bound to avert death when it is in his power ? 
or, at all events, is he not bound to do, at the moment he is obliged 
to decide, the best he can for his patient ? This certainly will be an- 
swered in the affirmative : for he has nought to inquire whether death 
might not be preferable to life, upon the terms he can give that life. 
For if he decide that it is, and he permit his patient to die, rather 
than subject her to the penalty, that the preservation of her life will 
impose upon her, he is guilty of species of murder. It is, therefore, 
decidedly his duty, his imperious duty, to preserve life when it is in 
his power, be the terms of that preservation what they may. 

1310. If this be granted, it will also be ceded, I trust, that I was 
acting strictly in the line of my duty, in affording the only apparent 
chance for life, or even of comfort, to an almost expiring woman. 

1311. That it was an experiment, is granted ; and its success, was 
yet to be proved ; it turned out fortunately, and rescued the patient, 
I honestly believe from death ; and if the history of this case be care- 
fully read, (case second,) it will be seen, that it was considered alto- 
gether hopeless, after the attempt at reduction, which was conducted 
with all the little ability I was master of, had proved fruitless ; and 



412 INVERSION OF THE UTERUS. 

that the patient might be considered " articulo mortis ;" I therefore 
think there can be little doubt, that I did the best the situation would 
permit. 

1312. I would ask for information, what better could have been 
done under the existing circumstances? for the patient was almost 
expiring ; and would have very quickly died if relief had not been 
afforded. The attempt at restoration, the only one on which we 
could rely, it is seen had failed; the " anceps remedium" presented 
itself; and it proved successful. But let me now be clearly under- 
stood upon this subject, as declaring, that the proposition in question 
is never to be acted upon, but as the dernier resource ; and that I 
have never proposed it but as such, will, I think, distinctly appear, 
if what I have said be carefully read. 

1313. It is asked, " Is there no chance of reducing the uterus 
after the stricture is removed'? I would ask, in turn, can the stricture 
be removed ? Has the writer ever known it removed ? If he have 
not, I think the question answers itself, since we have no control 
over it ; and we fear we can not have, as a little reflection on the 
situation and functions of the parts, will show almost its impossi- 
bility ; for which reason I am decidedly of opinion that a " complete 
inversion " never has been reduced. It is true we may suppose a 
case, and then deduce the possibility of restoration in complete in- 
version — we may imagine the neck of the uterus to be in a state of 
relaxation ; and if it be so, no difficulty in the restoration of the 
fundus presents itself. But let this condition be proved to exist, be- 
fore we speculate upon the advantages that would result from such 
a state of things. See pars. 1268 and 1339, &c. and fig. XVII. 

1314. It will be seen, at once, by reference to the structure of the 
parts concerned in this accident, that the structure in question is 
nothing more nor less, than a natural, or functional condition of the 
os uteri ; for a state of contraction is the natural state of this part, 
when its functional powers are in a healthy condition ; consequently, 
it always closes after the contents of the uterus are discharged. It 
seems, that the writer of the article under consideration, looks upon 
the stricture, " as an accidental state of the os uteri, and that this 
condition can be removed by remedial agents;" than which, in our 
opinion, there can be no greater error. If this " stricture " was the 
effect of spasm, or of some accidental state of the os uteri, we might, 
perhaps, find a remedy for this unfortunate condition of the part ; or 
it might after a given time, relax itself, but when it is well known 
to be the natural result of its structure, and that nothing but force 
can possibly overcome it, we may look in vain, I fear, for remedies 
to relax it. 

1315. If the os uteri were flaccid during an inversion, the chance 
of restoration would be greater, nay, nearly certain ; but as this con- 
dition can only be the result of a diseased state of this part, it will 
only take place from an accidental combination of circumstances, 



INVERSION OF THE UTERUS. 413 

which we can neither command nor control. The only agent we 
have at command is mechanical force : now, we know, that this 
power can very rarely be successfully, or even safely employed, for 
the reason above suggested, (pars. 1300, 1301, 1302, 1303, &c.) I 
shall mention, however, presently, that this relaxed condition of the 
os uteri sometimes exists. 

1316. But, with a view to render this suggestion certain, or, at 
least, occasionally successful, it is stated in the gross, that restoration 
had been performed, after complete inversion, by a physician who 
gave the account himself. He says, that he had restored the fundus 
after the lapse of forty-eight hours, and that the "inversion was com- 
plete." We are not favoured with any of the particulars of this case 
to prove it to have been complete ; we are obliged to abide by a 
bare ipse dixit, which seems to be at once contradicted by the very 
mode employed for the reduction, as we shall attempt to show. See 
fig. XVI. 

1317. But, before we proceed farther, let us observe, that the 
term u complete inversion" has almost always been vaguely em* 
ployed. When the fundus of the uterus escapes through the os ex- 
ternum, it is called by Drs. Denman, Merriman, Mr. Burns, M. Le- 
roux, and others, a complete inversion, of the uterus ; thereby making 
the situation of the fundus the distinctive sign of a complete inver- 
sion, instead of the condition of the neck of the uterus. Now, if 
this definition be admitted, we may look for many instances of the 
reduction of a ''complete inversion," without a single genuine in- 
stance occurring to authenticate the success of the operation. For 
I have seen more than one instance of partial inversion, in which the 
fundus was protruding through the external parts, and could cite 
many more. 

1318. The reviewer farther states, that " there was a period in the 
above case, (case second,) in which reduction might have been per- 
formed." This, however, is merely opinion, and cannot be either 
proved or disproved ; yet, with a view to this, he says, " the woman 
was delivered by a midwife on Friday. Dr. Dewees and Dr. Atlee 
were not called until the Thursday following. These facts are 
worthy of notice ; for should partial inversion occur, and symptoms of 
strangulation come on, soon after delivery, and an insurmountable 
obstacle seem to exist to reduction; might not some other means of 
treatment be adopted, than the method of the author ? Would full 
opiates, warm bathing, and even blood-letting, be advisable, in the 
first instance ; followed by attempts at reduction, when the effects 
were present, of all these means, or of some of them ?" p. 158, 
loc. cit 

1319. In answer to the above questions, I should hold it doubtful, 
whether the writer of the review had ever witnessed a case of in- 
verted uterus. If he had, I think he would not have proposed warm 
bathing, or blood-letting, where symptoms of strangulation had come 

36 



414 INVERSION OF THE UTERUS. 

on. He would have known that an overpowering flooding almost 
always attends a partial inversion, and for which the warm bath 
would be considered a very doubtful remedy, to say the least of it. 
He would also have known, that faintness, exhaustion, vomiting, and 
almost extinct pulse, are sure to accompany a strangulated uterus, 
and, consequently, that blood-letting is not indicated or to be thought 
of. Opium is the only one of his proposed remedies that can be 
used with advantage ; and this has always been given in large and 
frequent doses, the instant severe pain has shown itself; but with no 
other advantage, as far as I have seen, than to diminish pain ; it can- 
not relax the contracted os uteri. 

1320. He, however, in a subsequent sentence, says, " the situa- 
tion of the author's patient seems to have been truly desperate, and 
to have fully warranted the bold and novel treatment adopted," p. 
158. We are perfectly aware of all the evils that will arise from 
this new relation of the parts of the uterus; and also that nothing 
short of an absolute necessity can justify the execution of the plan 
proposed. 

1321. If he be asked, are there no instances of the reduction of 
the uterus under desperate circumstances'? and if we are to doubt the 
histories of such cases as purport to have been successful, where a 
number of days have elapsed after the inversion had taken place ? 
I say yes, to the first question ; and I would certainly say, in answer 
to the second, that we are not to doubt the truth of such histories, so 
far as the opinions of the relaters constitute the truth. By these conces- 
sions, however, I am not to be charged with deserting the position I 
have taken ; for though I admit every thing that the above questions 
in their general sense require, I must still insist that hitherto I have 
not met with an instance in my own practice, nor in that of any one 
else, of a well established case of u complete inversion," in which, by 
any efforts or perseverance, the fundus of the uterus has been placed 
in situ. I have no hesitation to believe that the os uteri may remain 
for some time uncontracted, or after some time become relaxed after 
such contraction, in partial inversion ; and that in such cases, a well- 
directed measure may become successful. But it must be remem- 
bered, where such instances of success have occurred, there was an 
absence of all severe and threatening symptoms ; an evidence that 
the neck of the uterus could not be very strictly girding the pro- 
lapsed portion. One of the most remarkable and instructive cases 
of this kind is related by Dr. Teallier, in Journal Universal, for 
Nov. 1823. 

" A Madame R., twenty-five years of age, was delivered on 2d of 
September, 1823, after a labour of thirty-six hours. The placenta 
was extracted without difficulty, and the patient was put to bed com- 
fortably. She continued pretty well until the 12th, when Dr. T. was 
called at one o'clock in the morning to his patient, who, in making 
violent efforts to pass the contents of the rectum, felt a bulky mass of 



INVERSION OF THE UTERUS. 415 

flesh descend through the vagina, which, though it did not produce 
much inconvenience at the time, was followed in about an hour by 
great pain in the belly, the displaced parts and in the groins, with a 
strong effort to vomit and a sensation of faintness. She was much 
alarmed, and retired again to bed, supporting between her thighs a 
smooth tumour of a deep red colour, of the size and shape of a large 
pear — its large extremity was resting on the thighs, its pedicle was 
tied within the labia. Dr. T. proceeded to the reduction by return- 
ing the tumour into the vagina, but in endeavouring to restore it to 
its natural situation, the hardness and the contraction of the neck 
rendered it impossible ; the sensibility of the organ being so much 
augmented, that the least pressure produced violent pain. Dr. T. 
suspended his attempts with the intention 'to renew them when cir- 
cumstances were more favourable. The patient was placed upon 
her back* ; the pelvis elevated ; the thighs closed ; and emollient fo- 
mentations and injections were employed — a rigid diet was observed 
for the first twenty-four hours. There was no hemorrhage, but little 
pain in the abdomen, or fever. 

"On the evening of the 1 3th an obstinate cough came pn, attended 
With fever, and some pain in the abdomen ; but a large bleeding on 
the 14th removed these symptoms. On the 18th, the condition of 
the patient continuing favourable, and Dr. T. finding the tumour to 
soften and become smaller, determined on another attempt to reduce 
it to its natural situation, in which he succeeded in one hour and a 
half, making, during this time, a moderate and continued pressure 
with the hand. No symptoms of consequence followed, that were 
ascribable to the accident." 

1322. This case is remarkable on several accounts: first, The 
uterus contracting healthily immediately after delivery, and conti- 
nuing in this condition for several days ; secondly, An entire relaxa- 
tion of this organ taking place ten days after delivery ; for though 
violent efforts were made to empty the rectum, yet these efforts could 
not be the primary cause of the inversion ; and that for during this 
time the uterus must have passed through the os externum, and have 
required the relaxation of the neck and other portions of the uterus ; 
and for the irritation of the rectum, and the consequent action of the 
abdominal muscles, could not induce this condition, though they 
might contribute eventually to the inversion. It is, therefore, more 
probable that the inverted uterus was the first cause of these efforts, 
by pressing powerfully upon the rectum ; and the inversion confirmed, 
by the straining it created. 

1323. Thirdly, The entire contraction of the uterine vessels; as it 
is expressly stated, there was no hemorrhage ; and it is also mentioned, 
the tumour was " smooth," which would not have been the case, were 
the uterus not well contracted.* 

* Smoothness is necessarily relative — for we cannot believe that this condition of 
the tumour could exist but in a moderate degree ; for, however firmly the uterus may. 



416 INVERSION OF THE UTERUS. 

1324. Fourthly, The gradual subsiding of the few unpleasant 
feelings, and the reduction of the uterine tumour, after a short time, 
manifesting the relaxation of the neek of the uterus, so as to admit the 
repassing of the inverted portions. For it is evident that this must 
have happened, since there were a few distressing symptoms, imme- 
diately after the inversion, such as pain, sickness, and faintness, which 
were certainly owing to the body and fundus being slightly strangu- 
lated, but which soon subsided, by the mouth of the uterus relaxing 
sufficiently to permit the reduction of the inverted portions. 

1325. Fifthly, It proves that, in "partial inversion," reduction may 
take place under certain circumstances, and by proper management, 
at least six days after the accident. For we must insist that this was 
a case of " partial inversion," as the neck of the uterus is charged 
with the difficulty of reduction, on the first attempt for this purpose. 

1326. In the inversion the uterus is the very reverse of its natural 
situation ; its internal face now becomes the external ; while the ex- 
ternal or peritoneal surface becomes the internal, or the uterine cavity, 
if we may so term it— it is probable that the ovaries, tubes and broad 
ligaments will be included in this space. Dr. Penman informs us 
these surface's do not coalesce. The woman may menstruate from the 
now external surface.. 



Case First. 

On the 2d July, 1807, at ten o'clock, A. M., I was called to the 

wife of Samuel N , in labour with her first child. Her pains were 

weak and irregular, but pretty frequent ; presentation perfectly natural. 
As every thing appeared promising, I left her to the care of her mid- 
wife. At four o'clock, P. M., she was suddenly delivered — con- 
siderable hemorrhage with faintings followed. I was again sent for, 
but did not see her until six o'clock, as she lived at some distance 
from the city. I found her without pulse, cold, and covered with 
perspiration ; with laborious and hurried breathing ; the placenta not 
delivered, and the hemorrhage continuing. I ordered her such reme- 
dies as appeared most pressingly indicated, and immediately examined 
her per vaginam. I found the placenta just within reach of the finger, 
and attempted to withdraw it, but it gave great resistance and extreme 
pain. I now introduced my hand, and found a tumour resembling 
in shape and size the swelling at the bottom of the common black 
bottle, and over which the placenta was spread. This case was per- 
fectly new to me, in a practical sense, although I strongly suspected 
the nature of the accident. I searched for the detached portion of the 
placenta, from whence the flooding proceeded, and carefully detached 
this mass from the tumour ■; I then endeavoured to push up this body, 

have contracted, its internal (now its external) surface could not but display, to a greater 
or less extent, a rough surface, especially at that portion on which the placenta had 
l?eea piaqed. 



INVERSION OF THE UTERUS. 417 

but quickly desisted, from the extreme pain it occasioned, and the 
uncertainty that it was the best mode of proceeding to procure relief. 
My patient died in half an hour. I obtained leave to inspect the body, 
and Dr. Rush very kindly accompanied me. It proved, as I had pre- 
viously suspected, to be a partial inversion of the uterus. I dissected 
out the uterus, which was still so flaccid, as to be turned inside out 
with as much facility as a soaked bladder. The fundus dipped into- 
the body of the uterus about three inches.* 



Case Second. 

On Friday, 24th March, 1808, at half past five o'clock in the morn-, 
ing, Mrs. P.* was delivered of a living child; her waters discharged 
themselves six or seven hours previously, and before her midwife was- 
called. The placenta came away spontaneously, as the midwife as- 
serted, and to which the patient herself agreed ; its expulsion was 
attended with great pain and great flooding ; she vomited severely for 
an hour, and several times fainted without an abatement of the dis- 
charge. This, however, was eventually moderated by the acetate of 
lead, and, perhaps, contraction of the uterus itself. 

After this, she continued pretty tranquil, but weak, until Sunday 
morning, when there was a renewal of the hemorrhage, with pains re-, 
sembling those of labour. These ceased in the afternoon; but she 
became more alarmingly ill. She now fainted frequently, and the 
discharge continued. In this way she kept until Tuesday, at which 
time I was called, at the desire of Dr. Atlee, whose patient she now 
was. The doctor suspected the true state of this woman's case, and 
mentioned his opinion to me to which, at first, I could scarcely assent,. 
as almost all the cases I had ever heard or read of, as well as I re- 
collected, had soon proved fatal ; and the case I had witnessed a few- 
months before, but served to make me doubt the doctor's representa- 
tion, or rather opinion. Here, if his judgment were correct, was an 
instance of inverted uterus of four day's standing; a case giving con- 
tradiction to all 1 had heard or believed on the subject. f I, however, 
visited the patient by appointment, and found her almost exhausted — 

* This case proves, what I have stated above, tint even a depressed fundus may 
prove fatil, by tlif excess of flooding; and consequently, we cannot trust such cases ; 
as we ennot ensure the entire adhesion of the placenta, nor always provoke the healthy 
contraction of t.ie body and fundus of the uterus, so as to secure the patient against 
hemorr 

+ Since writing the ab )ve, I have strong reason to believe, that the inversion did not 
take phec until the morning, namely, Sunday; on which there was a renewal of the 
flooding, and ihe occurrence of pains resembling a labour; and at this time, the uterus 
Buffered most probably a universal atony. 

At the lime alluded to, from my recollections of the opinions of others upon this 
subject, and the fetal case I had recently witnessed, my mind was disposed to doubt 
the existenee of this disease, especially of several day's continuance. Farther expe- 
rience, and refreshinrr my memory immediately after upon tie subject by re-consulting 
authorities, has r of course, altered the views I then had of its immediate fatality. 

36* 



418 INVERSION OF THE UTERUS. 

her pulse so frequent as not to be numbered, and so small as scarcely 
to be perceived ; had great difficulty in breathing, and became faint 
on the least motion ; insatiable thirst, frequent vomiting, cold extre- 
mities, and a continuance of uterine discharge. I examined her, and 
found, as Dr. Atlee had declared, the uterus to be inverted. The 
fundus was down at the os externum, and could readily be seen par- 
tially covered with a thin coagulum of blood, when the labia were 
separated. The places not hid by this coagulum, were rough or 
spongy, and of a dark brown colour. 

A very dreary prospect presented itself, by ascertaining this poor 
woman's situation ; we believed death to be inevitable. But one re- 
source offered itself, namely, to attempt the reduction of the fundus, 
hoping, as the uterus had not escaped from the vagina, the inversion 
might not be so complete, as to render this impossible. We accord- 
ingly proposed this attempt to the husband and friends of our patient, 
candidly stating her situation, and the almost certain result, if relief 
was not obtained in this way. They, without hesitation, submitted 
the case to our management. 

We carefully drew her to the side of the bed, and had the knees 
drawn up and supported. I gently introduced my hand under the 
tumor, and gradually raised it ; this gave me -sufficient room to ex- 
amine the nature and extent of the inversion. The instant I raised 
the womb, there was a large and sudden discharge of urine ; which 
gave still more freedom to an examination, that was to terminate in 
the disappointment of the hope of the reduction of the fundus. I 
found so much of it had passed through the mouth of the uterus, as 
to render any attempt at reduction futile ; and the more especially, as 
the tumor was augmented by its having swelled since it prolapsed. 
The stricture occasioned by the contracted mouth was readily felt, 
and was very strict. I was extremely perplexed for the moment how 
to proceed, or how to announce the failure of an attempt, which, 
alone, at first sight, appeared to promise success or even relief: but 
it fortunately occurred to me, before I withdrew my hand, that I 
might take off the stricture by inverting the uterus completely. 
Agreeably to this suggestion, I grasped the tumour firmly, and drew 
it pretty forcibly towards me, and thus happily succeeded in slipping 
the remaining portion through the constricting mouth. The woman 
w T as almost instantly relieved from much of the anxiety and faintness 
she had before experienced ; but as she was so exhausted by pre- 
vious suffering and discharges, and as the internal surface of the 
uterus was now exposed to the influence of external air, I was pre- 
vented from feeling, or giving the slightest encouragement of reco- 
very to her friends ; but fortunately the event proved how ground- 
Jess were my fears ; for, from this day, she rapidly recovered, with- 
out another alarming or troublesome symptom. 

Milk was freely secreted on the fourth day after, and continued 
freely. Our patient was twenty-three years of age, delicate, but 
always healthy, but more especially so during her pregnancy. 



INVERSION OF THE UTERUS. 419 

I visited this patient to-day, November 26th, 1808, and found her 
at the wash-tub, perfectly well ; suffers no inconvenience whatever 
from the uterus ; menstruated regularly for three periods ; had more 
or less discharge of mucus tinged with blood for four months ; this 
last four months has had no discharge of any kind ; suckles her child, 
which is remarkably thriving. The uterus is so much contracted as 
to be no longer within reach of her finger.* 



Case Third. 

On the 23d of November, 180S, Mrs. G , was suddenly deli- 
vered of a large female child, which breathed and cried freely imme- 
diately after its birth. The funis was not cut until after the pulsation 
in the cord had entirely ceased, which was in about ten minutes. 
After the child was taken away, I took hold of the cord, and merely 
tightened it, on which she begged me to wait, as it gave great pain. 
I, however, traced the cord to the vagina, and found at the os externum 
a placenta I thought unusually dense and large. On gently attempt- 
ing to withdraw it, as I thought it loose in the vagina, I found uncom- 
mon resistance, which I attributed to its bulk, and desisted from farther 
effort, hoping the uterus would, by contracting, push it completely 
down. In this I was disappointed; — some hemorrhage ensued. I 
now expected a more than common cause detained the placenta in 
the vagina, and began a more minute examination. I pierced the 
substance of the placenta with the fore-finger of my left hand, and 
tightened the cord with my right ; beneath the placenta I perceived a 
round hard substance, which I but too quickly discovered to be the 
fundus of the uterus inverted. I immediately introduced my hand 
into the vagina, and found the detached edge of the placenta from 
which the discharge proceeded. I carefully separated the whole of 
this mass, and withdrew it from the pelvis without the least difficulty. 
A considerable flooding ensued. 

As .Mrs. X 's case, (case first,) gave me a complete insight of 

the mechanism of this displacement of the fundus of the uterus, and 
as [ had resolved to attempt its reduction if ever an opportunity again 
offered, I instantly, after withdrawing the placenta, introduced my 
hand, and pressed the prolapsed fundus firmly with the back of my 
fingers, and carried it upwards in the direction of the axis of the 
uterus, and in less than half a minute, succeeded completely in re- 

* I was this clay, (June 1, 1810,) called to Mrs. P.on account of indisposition. She 
gave the following scconnt of her situation ; "She had been pretty regular ever since 
last report, hut for the last few periods it has been more abundant, and is sometimes 
accompanied by the discharge of coagula ; it continues longer than formerly, and, 
when i' ii followed by profuse fluor albus." I then saw Mrs. P. again in 

April, ISIS, and found her enjoying a very fair proportion of health — the catamenial 
discharge? had ceased for the last five years, and she had been a widow several years 
past. She has never been impregnated since her accident. 



420 OF TWINS, &c. 

storing it. Mrs. G. - had not an unpleasant symptom to follow 

this accident. 



Case Fourth: 

Mrs. G was delivered on the 24th of December, 1808, at six 

o'clock, P. M., after a labour of some hours, of her first child. The 
placenta was extracted in about fifteen minutes without force. There 
was some hemorrhage and considerable pain. She was put to bed, 
and became very faint, and complained of great pain, which was oc- 
casionally augmented. She continued in this way, only gradually 
becoming worse, until nine o'clock, at which time I was sent for. 

I found her with a small frequent pulse, great anxiety, extremely 
pale and cadaverous, and in a profuse cold sweat. I inquired re- 
specting the flooding ; but this did not appear to be sufficient to ac- 
count for her present situation. I immediately suspected a partial 
inversion of the uterus, and thought proper to apprize her friends of 
the probable cause of her distress and danger, and of the possible 
result of it. Every thing was left to my management. I immediately 
after examined her per vaginam, and found my conjecture true. 

The uterus was found inverted, and its fundus was just within the 
os externum. I was much alarmed for the patient, as three hours and 
more had elapsed between the time of her delivery and my being 
called ; she was much exhausted, and in extreme agony. I quickly 
introduced my left hand into the vagina, and applied the back of my 
fingers firmly against the tumour, while I moderated its influence in 
carrying the uterus directly up through the pelvis by having a gentle 
pressure made upon the abdomen above it. The tumour soon began 
to yield, and in about two minutes the fundus was completely re- 
stored. 

On the third day after, my patient complained of a severe pain in 
the right side just above the ilium, for which I bled her freely, and 
purged her briskly. Nothing unpleasant supervened ; she might be 
said to have had a good getting up. 



CHAPTER XXXV 



OF TWINS, &C. 



1327. Under this head I shall consider pregnancies composed of 
two or more children. Twins are of rare occurrence ; so much so as 
to render it difficult to establish the proportion between them and 



OF TWINS, &C. 421 

single births ; especially as their production seems to be governed by 
contingencies not within control, or altogether inscrutable. Thus, in 
the Middlesex Hospital, London, there was but one in about ninety- 
one, while in Dublin the proportion was greater. In France, agreea- 
bly to one return of " l'Hospice de la Maternite," the proportion was 
about one in eighty-eight ; but, according to that of Madame Boivin 
of the same institution, the proportion was only one in about one 
hundred and thirty or forty, while in that of the " Maison d'Accouche- 
mens," the proportion was about one in ninety-one. 

1328. In this country the average is about one in seventy-five. 
From this it would appear, that climate or the state of civilization, 
agreeably to the remark of Dr. Denman,* exerts an influence upon 
the multiplication of the human species ; and that where the means 
of life are more abundant or more easily procured, the proportion of 
twins is probably increased — this, however, is by no means proved ; 
but that there are conditions and circumstances which give rise to 
more double births in this country is certain, if reliance can be put 
upon the various tables of births. f It would be a curious subject 
of inquiry for the political economist, and the physiologist, to ascer- 
tain on what depends the frequency of plurality of children. 

1329. It is presumable upon general principles, that whatever con- 
tributes to fecundity in any country, will also contribute to the pro- 
duction of twins, &c, since a certain proportion must exist. We 
have just said that the power of reproduction is most probably in- 
fluenced by the facility of procuring the means of life ; this appears 
to be the case from the investigation of M. Benoiston, as published in 
the Revue Medicale for December ; he concludes that wherever ex- 
istence is easily supported, there will be found an abundance of chil- 
dren, which would seem to procure from the same cause a greater 
proportion of twins, &c. 

1330. It is thought by many women, that the disposition to double 
births is hereditary; and some facts within my own knowledge seem 
to countenance this supposition, but they are by no means sufficiently 
numerous, or sufficiently strong to confirm it. I can say, however, 
with some safety, that it is in some instances constitutional ; I know 
one female, who has had five twins in succession, and had not, when 
I had conversed with her on the subject, (some years since,) ever had 
a single birth. I knew another who had twins three times, but not 
immediately following each other. 

1331. Were I to decide from my own practice, the proportion of 
twin cases would be greater than I have stated above, (1327 ;) it 
would be one in about fifty or sixty — but this computation would not 
be altogether correct; as I have been for many years occasionally 
called to the aid of midwives m this city, among whose cases there 
were a number of cases of twins — this would increase the average as 

* System, Francis's ed. p. 534. 

t Francis's ed. of Denman, in a note, pp. 613, 614. Dr. Arnell's average is one in 
seventy.five ; Dr. Moore's, one in seventy-six. 



422 OF TWINS, &c. 

regards my own practice, without giving a just view of their frequency, 
since these cases should be considered as properly belonging to the 
averages of these midwives. 

1232. Triplets are very much more rare. In the returns of the 
cases in the " Maison d'Accouchemens," as furnished by Baude- 
locque, there appears to have been but one in more than eight thou- 
sand cases ; in the return of Madame Boivin, of the cases of " PHospice 
dela Maternite," one in rather less than seven thousand ; Dr. Arnell, 
one in twelve hundred, and in my own practice, in more than ten 
thousand cases, I have not met with an instance of triplets. Of more 
numerous progeny the proportion must be infinitely small ; since, in 
the practice of the two hospitals above mentioned, in the private 
practice of Drs. Arnell, Moore, and myself, amounting in all to more 
than fifty thousand cases, there is no mention of an instance of four 
children born at a birth. 

1333. We are farther informed by Professor Duges, that agree- 
ably to the register of "la Maison d'Accouchemens de Paris," for 
twenty years, the following proportion of twins and triplets were 
registered. 

In 37,441 deliveries, there was 36,992 single births ; 444 twins ; 
five triplets ; but no instance of more numerous progeny was ob- 
served, either in " PHospice de la Maternite," at least up to the year 
1821, nor in the Hotel Dieu, before the establishment of the maternity, 
for sixty years previous to the year 1821 ; though the total amount of 
cases in these institutions amounted to 108,000. 

1334. But he adds, that " instances of quadrigeminii have occa- 
sionally been met with. Lately the- journals have announced a case 
of this kind : and a similar instance occurred in Paris, in October, 
1823; and Gottleib mentions a case of a woman at Strasburg, who 
had eleven children at three deliveries, of course making a recurrence 
of quadrigeminii twice, and of triplets once.' ? *f 

* Revue Medicaid, torn. 1, p. 340. 

t As regards the number of foetuses, fable has exerted itself to an almost endless* 
extent; thus the story of the Countess of Hannenberg may be cited as an instance, 
She, in consequence of a curse pronounced by a beggar-woman on her, to whom she 
had refused money, was delivered of three hundred and sixty-five foetuses, that is, one 
for every day in the year, in fulfilment of the wish of the offended mendicant, which 
was, "that she might have as many children at a birth as there are days in the year.'* 
The curse was said to be accomplished ; and in proof of it the foetuses are shown to 
strangers that visit the museum at Leyden. This fable did very well for the year 
1276; but, were the like to happen now, it would be most scrupulously investigated, 
and more rationally accounted for. Inthe case just noticed, the sexes were pretended, 
to be discoverable; and all the males were called John, and all the females Elizabeth, 
at their baptism. 

A slight resemblance in former times, was sufficient to elicit a name similar to the. 
supposed prototype ; this was particularly the case in the nomenclature, of anatomy — 
witness the names of the different portions of the brain; the bones of the wrist, and of 
the foot. It, therefore, required but a trifling exertion of the imagination, in former 
times, to fashion coagulated fibrin into embryos, as it very much resembles human ru- 
diments of five or six weeks old ; for we have frequently been consulted about the 
nature of this product, in cases of dysmenorrhoea ; and, indeed, the resemblance is 
much stronger than we should at first sight imagine. I would, therefore, account for 



OF TWINS, &c. 423 

1335. In this country it is not very unusual to find announced in 
our public prints, instances of four children ; it may, however, be 
questioned whether such are as frequent as such proclamations de- 
clare. We, however, find in the Albany Argus, the following ac- 
count of " unparalleled fecundity." Dr. 0. F. Paddock, a respecta- 
ble physician of Fort Covington, Franklin county, gives in the Frank- 
lin Telegraph, an account of an extraordinary birth of five children 
at one time, from the same mother — three daughters and two sons. 
There are two instances of this kind recorded in that excellent Jour- 
nal, Am. Journ. Med. Scien. ; one in Feb. 1838, p. 459, and the 
other for Feb. 1840, p. 485. The latter is said to have occurred in 
Naples ; and which we will briefly relate. The mother of these 
children had borne twelve at ten accouchments. She was at the 
seventh month of her gestation ; she suffered nothing comparatively 
— five were baptised ; they weighed three and a half pounds each — 
the funes and membranes were four instead of five, each had its pro- 
per umbilical cord except the fourth, which contained two in an en- 
closed sac. The foetuses with their membranes, placental and um- 
bilical cords are preserved in the Royal Anatomical Museum of Na- 
ples. Four of them were born alive, but lived a short time. The 
birth was premature three months, but they were perfectly well- 
formed and well-shaped. The average weight was about two pounds, 
and not much difference in their size. Their parents lately emigrated 
from Ireland, and arrived in this country in August last. This is 
rendered more remarkable by the fact, that the mother of these five 
was delivered on the 20th of last February of two — making, in the 
whole, seven children in less than nine months. The last were born 
on the 25th November, 1826. " Dr. Ryan, the learned editor of the 
London Medical and Surgical Journal, states that he was called to a 
patient, aged forty-one, of a sanguine temperament, who had men- 
struated at the age of twelve, and married between eighteen and 
nineteen. She had a seven months' child in the eighth month of her 
marriage — had twins about the fourth month three times during the 
year 1829, and again in December 31, when she was attended by 
Mr. Whitemore, of Cold Bath Fields, and delivered of two infants ; 
and on January 28th, 1830, she was attended by Mr. Thomas, of 
Bagnigge Wells Road, and delivered of an infant, which he consi- 
dered of the same age as the preceding. On the seventh of June 
last, (1830,) she aborted at the third month ; and on the 9th, a se- 
cond foetus was expelled ; she was attended by Mr. Sandell. ; and as 
there was no discharge whatever from that time to this, considers 
herself still pregnant. The abdomen is about the size of a woman 

the enormous (supposed) progeny, of the Countess of Hannenberg, in this manner; 
namely, that she had discharged per vaginam, a large quantity of modified fibrin, in 
consequence of some pathological condition of the uterus ; especially as she had ar- 
rived at that period of life in which menstrual aberrations are common ; for it is stated 
she was about forty years old. Dr. Ramsbotham supposes them to have been polypi, 
but we are of opinion that it was altered fibrin, for the reason stated above. 



424 OF TWINS, &c. 

in the fifth month of utero-gestation. She has had twenty-four chil- 
dren in twenty-one years. She menstruated regularly before marriage. 
She is always in good health when suckling, and ill when breeding ; 
she always becomes pregnant about the fifth month of lactation. Her 
mother is seventy years of age, and is in good health ; she has had 
eighteen children born alive. A relation of her husband has had 
thirty-two children including miscarriages." Amer. Jour, of Med. 
Sciences, for Feb. 1831. The author has lately conversed with a 
lady, who was then in her thirty-eighth year, who declared to him 
that she had been pregnant two and thirty times ; of this number 
eleven were born alive and at the full time. She repeatedly miscar- 
ried of twins, and no abortion was less than near three months. She 
had been married nearly twenty-three years. 

1336. The case (1335) is styled unparalleled ;" but Dr. Duges 
states, that there is a case mentioned,* on the authority of Petretein, 
a Greek Physician, in which the woman was delivered prematurely, 
(seven months,) of three living females, and one dead, and one boy, 
all equally well developed. f 

1337. Women who are more than ordinarily large, are apt to 
suspect themselves pregnant with twins, and on this account much 
anxiety is always expressed. The accoucheur is not unfrequently 
consulted, and his opinion requested, on this momentous subject, so 
soon as this fear is excited ; but much caution should be used in an- 
swering this question ; indeed, it should always be resolved in the ne- 
gative, and for two reasons especially ; first, because it is impossible 
to decide it positively ; and secondly, if it could be, it never should 
be, as much mischief might arise from the uneasiness it might pro- 
duce. 

1338. We have no certain marks before labour by which we can 
determine there is more than one child in the uterus : a number of 
signsf are recorded, purporting to declare this condition ; but not 
one of which can be positively depended on. Baudelocque and 
Denman say the same thing : the former is of opinion that the union 
of all these signs sometimes gives strong presumption of the existence 
of twins, but that " touching alone can dissipate our doubts, and that 
only at the last months of pregnancy." " For," says he, " when 
the belly is so large as to give the suspicion of two children, if there 
is but one, it is always very moveable, because it is then in a large 
quantity of water : we easily move it by means of the finger intro- 

* Biblioth. Med. torn. 19. p. 374. 

t Revue Med. loc. cit. 

t The enumerated signs which purport to decide the woman to be pregnant of twins, 
are — 1. The extraordinary size of the abdomen of the woman. 2d. The diversion of 
the abdomen into tumors upon its anterior surface, occasioned by the unequal stretching 
of the recti muscles. 3d, An cedematous condition of the inferior extremities, after 
the third or fourth month ; and, 4th- The various or numerous places at which the 
woman feels motions or stirrings. Dr. Kennedy, of Dublin, and others have declared, 
that the motions of two hearts can be distinctly perceived by the application of the 
stethoscope. 



OF TWINS, &c. 425 

duced into the vagina, and its rolling is never more manifest than 
when we do that. When there are two, that movement is scarcely 
sensible ; we easily distinguish that the child we endeavour to move 
by touching, is surrounded by only a little fluid, and that it is en- 
cumbered by another solid body ; if we apply the hand on the wo- 
man's belly in one of these movements, when the parietes of the ute- 
rus are supple, and as it were, slackened, we may discover these 
children as clearly as in other cases we distinguish the feet, the knees, 
or the arms of that which is single."* 

1339. The whole of the information we can gain, either by taking 
into consideration the enumerated signs, or by touching, as proposed 
by Baudelocque, can never amount to more than presumptive evi- 
dence ; as the whole of the signs have been known to exist without 
the woman being pregnant of twins. And the quantity of liquor 
amnii differs from a few ounces to several pounds in even single 
pregnancies; therefore, no certain conclusion can be drawn from the 
mobility or immobility of the fcetus in utero. 

1340. Dr. Duges says, " the most unequivocal sign of the exist- 
ence of twins, is the presence of two pouches of water at the orifice 
of the uterus. He says he has met with this circumstance ; so also 
does Madame La Chapelle. One of these pouches may be more 
round than the other, and contain some portion of the foetus ; the 
other is flattened and curved, (courbee,) and for the most part con- 
tains only the liquor amnii. "f I have never met with such an in- 
stance ; nor do I recollect it having been mentioned before. 

1341. The uncertainty whether a woman be pregnant of one or 
more children, fortunately is of no consequence, until the labour has 
positively commenced ; for, previously to this time, our conduct in 
every respect should be the same as if there were but one child. 
But at this period it would in many instances be extremely useful, 
when the children were offering untowardly ; as the cause of diffi- 
culty would then be ascertained, and the indications fairly declared. 
In cases of twins, the situation of the children, either as regards 
themselves or the pelvis, may be more or less favourable, and con- 
sequently, complicate the labour in proportion. 

1342. The situation of twins or triplets may be such as regards 
each other, as to offer almost insuperable difficulties to delivery. 
Such was the case, in the history of a twin labour, given by Dr. Ir- 
win : the head of one foetus was placed so closely over the neck of 
the one which presented the breech, and was delivered all but the 
head, that this part could not be made to descend by any force, or 
ingenuity, that this physician could employ. The crotchet was re- 
solved on and used : after this, by great exertion, the head was ex- 
tracted ; but to the surprise of the gentleman, it was uninjured by 
the crotchet. This pointed out the situations of the heads of the 
children, as stated above. 

* System* Vol. III. p. 442. t Revue Med. loc, cit. 

37 



426 OF TWINS, &c. 

1343. Dr. Clough* also met with an instance, in which great diffi- 
culty was experienced, but not equal to the one related by Dr. Er- 
win. Such cases bid defiance to rules : every thing must be left to 
the good sense and discretion of the practitioner. 

1344. Twins may, first, be enclosed in one common covering of 
membranes, and inhabit the same nidus, and float in the same wa- 
ters ; secondly, they may each have a separate amnion, while the 
chorion may be common to both ; thirdly, each may have its own 
membranes, waters, and placenta. 

1345. The different situation in which twin children may be placed 
while in utero, especially the first two, (1344,) disturb every projected 
scheme, with respect to impregnation ; they unsettle that which has 
been hitherto thought pretty well proved, as regards the ovaries, the 
fecundation of ova, and the absolute nature of the ovum itself; and 
throw into confusion that which has been thought clear ; or, they 
oblige us to extend our notions of the powers of the corpora lutea, 
very much beyond what they have hitherto been. 

1346. They disturb, (1344,) all the schemes for impregnation, 
since they all suppose, that each ovum is a separate and distinct germ, 
and included in distinct coverings ; yet two are found involved in the 
same common covering with two umbilical cords, and with one pla- 
centa. It unsettles that which has been thought pretty well confirmed 
as regards the ovaries, to wit : that they furnish ova, for impregna- 
tion, upon different portions of its surface, yet two embryos are found 
to bathe in the same waters, and with one placenta for their support ; 
providing, it would seem that an ovum may contain more than one 
germ, which may be fecundated at one and the same time. They 
throw into confusion that, which has, especially of late, been thought 
perfectly clear and well understood, as follows : that the corpora lu- 
tea furnish the ova for impregnation ; that each corpus luteum yields 
its own ovum, and that each ovum brings with it, from its nidus, its 
own chorion and amnion ; yet they are both found common to chil- 
dren ; or the chorion alone common, and each has its amnion : yet 
with distinct chords and a placenta in common — now, I would ask, 
how this can be, agreeably to our present notions of impregnation ? 
Does it not oblige us to extend the powers of a corpus luteum, and 
make us admit, that one ovum may contain the rudiments of two 
foetuses, or oblige to call in question the arrangements just spoken 
of?f (1345.) 

1347. The third situation of foetuses in utero, (1344,) proves, that 
two ova may furnish embryos with their own coverings, since they 

* Lond. Med. Journ.vol. 25. 

t May we not reasonably doubt, that two children can float in the same waters as 
an original disposition of them ? May we not suppose that the muscular exertions of 
the children may have broken the separating membranes, and thus permitted the wa- 
ters to unite 1 For it cannot be doubted, that they have been found together : as Dr. 
Denman, (Francis's ed. p. 541,) tells us, his friend, Dr. Sims, informed him of a case of 
twins, where the funes were so closely twined together, as to appear but one. 



OF TWINS, &c. 427 

exist separately and distinctly in some cases of twins : and their 
separate existence renders it more than probable that they were the 
product of different ova, and as probable that each issued from a 
■separate ovarium. For, if we do not admit this, we must allow 
that, which not only wants proof, or even probability, and very much 
more difficult to reconcile ; namely that a Fallopian tube can success- 
fully- transmit two ova at one and the same time, or consecutively ; 
which agreeably to all the present known schemes of the ovum 
getting possession of the uterus, would be very difficult to reconcile, 
though not, perhaps, impossible ; but by admitting a simultaneous 
action in the tubes, and each ovarium furnishing an ovum, the ex- 
planation is easy ; therefore, to be preferred. But a truce with specu- 
lation. 

1348. The labour of a woman pregnant with twins, begins in 
every respect like a labour in which there is but one ; but its pro- 
gress, in general, is neither so regular nor so rapid. The latter cir- 
cumstance is not difficult to explain ; since it is impossible that either 
child can receive the undivided influence of the contracting uterus, 
and, therefore, it cannot be so rapidly expelled ; or, they may be so 
situated as to impede, if not to oppose, each other's exit ; hence the 
labour is slower, or at least with the delivery of the first of the chil- 
dren ; but with the second it may be quicker, nay, even rapid. This 
being the case, if we could even determine before hand that the 
labour is a twin case, we should not alter our conduct, except there 
be something in the labour itself, which would require interference, 
independently of its being a compound pregnancy. 

1349. In general, nay, almost always, we do not know we are en- 
countering a twin case, until after the birth of the first child ; we may 
then suspect this to be the case ; 1st. When the child is small com- 
pared with the size of the abdomen of the mother, and the quantity 
of water discharged ; 2d. If the abdominal tumour have not sub- 
sided as much as if it were a single child ; 3d. Because the child may 
be felt through the abdominal and uterine parietes ; 4th. Because 
there is in general, a renewal of uterine contractions, and the child 
can be felt per vaginam, if its membranes have given way, or the 
membranes themselves when distended with the waters if they are 
entire. 

1350. After the birth of the first child, and we have ascertained 
that there is a second, it then becomes a question, what is to be done 
with the second ? Accoucheurs seems to have puzzled themselves 
in answering this plain and simple question, and to have attempted 
to lay down rules, which are calculated to embarrass, rather than in- 
struct, the inexperienced practitioner. The rule upon this subject is 
plain, and void of all ambiguity, since it is founded upon the dispo- 
sition and the situation of the uterus itself. Baudelocque alone is 
rational on this subject. 

1351. I have said the rules of practice in cases of twins, after the 
birth of the first child, were free from all difficulty or ambiguity; for 



428 OF TWINS, &c. 

after one child is expelled, one of two things must happen, either 
that pains will pretty quickly ensue, and deliver the second if its 
position be natural, or that there will be a suspension of pain. 

1352. If the first case obtain, we must conduct the labour as if it 
were an original labour, and not to be interfered with so long as 
there is a rational expectation that nature is competent to relieve her- 
self; and if this promise be not made, or seasonably fulfilled, we 
must interfere as upon any other occasion, where interference might 
be necessary. When pains follow the expulsion of the first child, 
there is every expectation they will accomplish the delivery of the 
second ; first, because it will receive the whole influence of the 
uterus, which was divided before ; secondly, because the subsequent 
pains will be more powerful than the antecedent ones ; since the 
uterus is now smaller, and its tonic contraction more perfect, which, 
(cseteris paribus,) always increases the alternate contractions of this 
organ ; thirdly, because- the parts have been dilated, and are of 
course made to yield by the passage of the first child ; therefore, there 
is less resistance to be overcome. 

1353.. If the second situation, namely, where there is a suspension 
of pain, our duty is equally clear — -for it will depend altogether upon 
the situation of the uterus itself. This condition will consist in its 
being uncontracted or contracted. 

1354. If in the first condition, it will be attended with hemorrhage,* 
or be free from it — if with flooding, we are to deliver as we would 
in any other case of hemorrhage, and be regulated by the same rules 
which govern upon such occasions ; if no hemorrhage be present, we 
must solicit the contraction of the uterus by frictions upon the abdomen, 
until it contract. If it be contracted and pains do not pretty soon 
follow, I have long thought it best to make the labour an artificial 
one, and for the following reasons. f 

1355. First, because if pains do not come on in the course of a 
half hour after the- tonic contraction of the uterus is well established, 
it is altogether uncertain when they will take place ; and the patient 
is then left in great anxiety for the event ; secondly, after the expul- 
sion of the first child, a hemorrhage or other accident may ensue 
which will oblige, us to deliver under all the embarrassments it gives 
rise to ; thirdly, there is nothing to apprehend in terminating the la- 
bour, as the tonic contraction is secured ; and no difficulty can be 
created, since ihe uterus will readily permit turning if the head pre- 
sent ; or to deliver, as directed when either the breech, feet, or knees 
present, when there is a necessity of making an artificial labour of 
the case ; fourthly, we remove at once the anxiety of the woman ; 
which, if long continued, may have a very unfriendly influence upon 
the powers of the uterus. 

* The same may be said of either of the other accidents that may complicate a 
febour, (65|.) 

f I believe it would be a g>ood genral rule of practice, when the contractions are 
feeble,, or very far apart, to administer the ergot. 



OF TWINS, &c. 429 

1356. All rules of conduct, taken from the lapse of time, are liable 
to very serious objections ; for mere waiting does not ensure the pro- 
per condition of the uterus to render our acting safe ; and we are 
never to proceed to delivery if that proper condition, (1201, 1202,) 
does not follow, however long we may have waited ; for, at the end 
of four hours, Dr. Denman's* rule,) it may be just as improper to de- 
liver, as it may have been at fifteen minutes after the birth of the 
other child ; and if contraction justifies us to deliver at the end of 
four hours, it justifies us at any intermediate period at which it may 
take place. And if we are to act at the end of four hours, be the 
condition of the uterus what it may (for nothing is said of the state 
of this organ,) we shall as certainly do mischief by our interference if 
the uterus be not contracted, as if we had acted at any other antece- 
dent period. If, then, we do not ensure the contraction of the uterus 
by waiting, we gain nothing ; and it will be proper, therefore, to act 
whenever we are assured, that the powers of the uterus are in full 
and healthy play, be this when it may. 

1357. Should any of the enumerated accidents (651) complicate a 
labour of twins, we musVaet as in any other case ; taking care at the 
time, to distinguish the proper feet, when we are about to bring them 
down, and when both sets of membranes are ruptured : but if they 
are not, and we discover it to be a twin case in proper time after we 
have commenced the operation, to be careful not to rupture the mem- 
branes of the remaining child. If the breech, feet, or knees offer, 
we must bring down the feet, or act upon them, as has been directed 
— or if the head present, and the labour be far advanced, we must 
use the forceps, though we are certain it be a twin case. Or should 
any thing untoward take place during the transit of the second child, 
we must act as the nature of the case requires, without reference to 
its being a twin. 

1358. In my estimation, Mr. Burnsf lays down two very doubtful 
rules for the management of twin cases — the first is, that " if effective 
pains do not come on in a quarter of an hour, the child ought to be 
delivered by turning." The second is, " if the position of the second 
child be such as to require turning, we are to lose no time, but intro- 
duce the hand for that purpose before the liquor amnii be evacuated, 
or the uterus begin to act strongly on the child. 

1359. If we were to act agreeably to these directions, we should 
almost constantly have cause to repent the enterprise ; for we certainly 
should do mischief by exposing the uterus to a state of atony; and 
thus provoke, perhaps, a fatal hemorrhage. I must repeat, in such 
cases, we should pay no regard to the time which may elapse after 
the birth of the first child ; it is to the condition of the uterus alone 
we should direct our attention, and that alone should regulate our 
conduct. For, if the uterus be well contracted, we may act at any 

* Introduction, Francis's ed. p. 540. 
t Principles, James's ed. p. 406. 

37* 



430 OF TWINS, &c. 

period it may be necessary, with perfect safety ; but if it be not, no- 
thing can justify the interference, save, that the patient may be at- 
tacked by one of the accidents enumerated above, (651.) 



a. On the Management of the Placentae. 

1360. From what has been said above, (1344, &c.) it will not al- 
ways be found that each child in twin cases will have its placenta ; 
yet it is generally the case ; and though only connected by interposing 
membrane, we are obliged to deliver them together. Before, how- 
ever, we make the attempt to deliver the placenta, when we have 
reason to suspect there is another child ; or when this has been ascer- 
tained, we should apply two ligatures upon the funis of the delivered 
child, and cut between them; as the cut extremity in £uch cases yields 
a good deal of blood sometimes; and occasionally, it is said, even to 
the exhaustion of the second child. We should never attempt to 
deliver the placenta in twin cases, until both children are born. 

1361. This bleeding may happen where* both funes belong to one 
placenta, or where the two children are supplied by one original cord, 
branching some distance from the placenta to furnish a funis to each 
— and, as we cannot beforehand ascertain such deviations, it is best 
to guard against the chance of mischief by the application of a liga- 
ture : this may be removed after the birth of the second child, that it 
may discharge some of the blood contained in the placenta, for the 
reasons before stated, (554.) 

1362. The delivery of .the placentas of twins must be -conducted 
upon the same general principles, as if there were but one — but 
rather more time should be given, and caution exercised in twin 
eases; because the uterus has been more distended during gestation 
and more severely exercised sometimes during parturition with a 
single birth : consequently, the tonic contraction will be more slowly 
and reluctantly performed, and the woman more exposed to flooding. 
Brisk frictions should be immediately instituted, and sufficiently per- 
severed in, to ensure the object for which they were employed. 

1363. When the tonic contraction of the uterus is confirmed, we 
may then, and never until then, proceed to the delivery of the pla- 
centae — they will be found either occupying the vagina, or be beyond 
the reach of the finger. If in the first situation, they may be extracted 
by a small force exerted upon the cords, and the aid of a finger intro- 
duced into the vagina. If in the second, we must co-operate with 
the uterine contractions, when they exist, by pulling gently, but pretty 
firmly by the cords, but not with equal force on each — if we do, we 
tend to bring both placenta? at the same time to the os uteri ; and 
their united bulks will not readily pass it — we should, therefore, act 
more firmly upon the cord first out, as it is more than probable its 
placenta is nearest the uterine orifice, and will more easily descend,, 
and at the same time bring the other with it.. 



OF TWINS, &C. 431 

1364. Should there be no pain to aid in the expulsion of the 
placentas, we must continue the abdominal frictions, and act occa- 
sionally upon the cords, by applying rather more force upon the first 
than upon the second, for reasons just stated, (1363.) A slight dis- 
charge of fluid blood, or small coagula, almost always announces the 
descent of the placenta; this is equally observed when there are 
two ; and when we find this taking place, we must continue a gentle 
attractive effort, until they are lodged in the vagina — from this they 
may be withdrawn, as already intimated, (1363.) 

1365. Dr. Denman says,* "When the placentae are separate, that 
of the child should not be extracted before the birth of the second 
child, as a discharge of blood must necessarily follow, and perhaps 
a hemorrhage." This certainly would have been rational advice, 
and highly useful, were we informed, how we are to know before- 
hand, when the placentae exist separately. I have already directed, 
(1363,) that the first placenta is not to be meddled with, in twin 
cases, until the second is ready for delivery; and with this direction 
I believe we must rest satisfied, without ascertaining whether it be 
separate or connected. 

1366. Dr. Denman farther says, "If there have been a necessity 
of extracting the children r^y art, it is commonly, but not universally 
necessary to extract the placentae also by art ; but if the placentae are 
detained beyond a proper time, we will say two hours, after the birth 
of the second child, it is desirable, though there may be no very 
urgent symptoms, that we should inform ourselves of the cause of 
this detention, and act accordingly." 

1367. The first of these remarks, namely, that, the interference of 
art is necessary to the delivery of the placenta?, if it has been neces- 
sary for that of the children, is by no means agreeable to my experi- 
ence ; nor do I see the slightest relation between these events ; and 
if acted upon by inexperienced practitioners, as it certainly will be, 
when advised by such hi^h authority, much mischief will ensue. 
And to the second, J must again object, as the rule is taken from time ; 
which can never in itself constitute a reason nor develope a principle ; 
for, as I have upon another occasion remarked, it may be just as 
improper at the end of two hours to deliver the placentae as it was 
immediately after the delivery of the last child. 

1368. If artificial means be resorted to, care should be taken that 
both placentae are detached from the uterus, whether they exist 
separately, or if they be merely joined by membrane; if there be but 
a placenta, it must be removed, as upon common occasions. 

1369. In cases of twins, a much larger surface is occupied by the 
placentae tha? if there were but one : we should on this account be 
very careful to renew the frictions upon the abdomen, after their 
expulsion, that the uterus may contract as much as possible; and 

* Francis's edition* p. .311. 



432 OF PRETERNATURAL LABOURS. 

thus tend to diminish the subsequent discharges, which are but too 
apt to be in excess. 



CHAPTER XXXVI. 



OF PRETERNATURAL LABOURS. 



1370. Agreeably to the classification I have adopted for labours, 
it will be at once understood, that the class termed preternatural, will 
consist of all such, as shall not present either the head, the breech, 
the feet, or the knees. Authors have made a very numerous collec- 
tion of preternatural labours : some of which occur so rarely, as to be 
seldom, or perhaps never met with, even by an old and experienced 
practitioner. 

1371. Baudelocque has been too lavish in his divisions and sub- 
divisions of this class of labours; as they 'serve rather to confuse than 
elucidate. To the inexperienced practitioner, his distinctions are ap- 
palling ; as they cannot well be retained in the memory ; consequently, 
cannot always be acted upon. But little injury can arise from the 
want of memory in this particular instance, provided the general prin- 
ciples which are to govern in such cases be recollected ; for they are 
all to be treated by "turning."* If, then, the principles laid down 
for " turning" be well recollected, little or no embarrassment can 
present itself. 

1372. It may, however, not be amiss to remind the inexperienced 
practitioner, of several of the most important rules upon the operation 
of "turning." 

1373. 1st. This operation must never be attempted so long as the 
os uteri is not dilated or easily dilatable. 

1374. 2d. That the woman must be placed upon her back, that 
the utmost freedom may be given to the operator's hands, and the 
buttocks, free from embarrassment which the bed-stead will neces- 
sarily create if not provided against. 

1375. 3d. That the time for the introduction of the hand into the 
vagina, is during a pain, after having been well lubricated. 

1376. 4th. But after the hand is in the uterus, every attempt to turn 
must be made in the absence of pain. 

1377. 5th. That it is rarely a matter of indifference, which hand is 
to be employed for the purpose of turning; therefore, the rule upon 
this subject must never be violated. 

* Except such cases as leave no doubt of the death of the child, and which may be 
terminated by the crotchet. 



PRESENTATION OF THE ARM AND SHOULDER. 433 

137S. 6th. That whatever be the situation of the child within the 
uterus, the feet must be brought into the pelvis, and the body must 
be flexed forward. See Chapter on " Turning." 

1379. I shall, however, treat of one ease of " preternatural labour," 
from the general class ; because it is by far the most frequent, as well 
as the most difficult — this case is the presentation of the arm and 
shoulder." 



CHAPTER XXXVII. 



OF THE PRESENTATION OF THE ARM AND SHOULDER. 

1380. Should the hand descend into the pelvis, either by not keep- 
ing it up as directed, (716,) when it accompanies the head or any 
other part; or when it seems to fall into that cavity at the time the 
membranes give way, it will almost always become a source of trouble ; 
especially if under the care of a'practitioner who supposes he cannot 
do better than to act upon it, to effect delivery. When the hand is 
not supported, so as to allow the head to descend without it, the arm 
is almost sure to come into the passage : this frequently, but not ne- 
cessarily, declares the shoulder at the orifice of the uterus. 

1381. Or the shoulder itself may present originally, without the 
hand being down, as a necessary consequence. This presentation is 
more frequent than any other, in which the head, knees, feet, or breech, 
do not present. The roundness of the shoulder favours its taking this 
position. 

1382. I have chosen to consider under one head the presentations 
of the shoulder, and the arm ; because the indications are precisely the 
same, as well as the mode of acting, for the arm itself produces no 
essential difference in treatment. 

1383. Before the mouth of the uterus is well opened, and the 
membranes are rent, it is difficult to distinguish the shoulders ; but 
when these changes have taken place, the clavicle, scapula, and ribs 
serve to distinguish this part. 

1384. The shoulder may present in four different ways at the su- 
perior strait: but these positions become very difficult to distinguish, 
unless the arm be down at the same time.* When the arm is down, 

* Velpeau thinks by his arrangement of these presentations of the shoulder, much 
ambiguity is avoided — he designates them by the titles of " dorso-pubic, dorso-sacral, 
and right and left dorso-iliac." We see no advantage in this — for in proportion as distinc- 
tions, (which are necessarily arbitrary,) are multiplied, the greater will be the confusion 
to the student. Indeed, Velpeau admits this himself just before, and instances, in proof, 



434 PRESENTATION OF THE ARM AND SHOULDER. 

the hand will serve to discover the position of the shoulder* The 
hand will offer itself at one of the sides of the pelves, and its back 
or palm, will present either anteriorly or posteriorly: the position of 
the shoulder must, therefore, in such cases, be learnt from the par- 
ticular situation of the hand. 

1385. In the first position of the shoulder, the head and side of 
the neck of the child is to the left side of the pelvis, and the right 
arm down ; the back of the hand will look anteriorly, the palm pos- 
teriorly. 

1386. In the second, the head and side of the neck will be toward 
the left iliac junction ; the palm of the left hand will then face out- 
wards ; the back will look to the posterior part of the pelvis. 

1387. In the third, the head and side of the neck will be to the 
right side of the pelvis ; the left arm down, with its back looking 
outwards, and the palm inwards. 

1388. In the fourth, the right arm will be down, with its palm 
looking outwards, and its back inwards. 

1389. If turning be resorted to, it will avail much to employ the 
proper hand. In the first and fourth, the right hand must be used ; 
in the second and third, the left. 

1390. In performing this operation, the rules laid down for 
turning in general, must not be neglected ; that is, the feet must be 
brought down in such a manner as to bend the spine anteriorly, 
&c, &c. 

1391. The presentations now treated of, are certainly very far 
from favourable ; yet they are by no means so menacing as is com- 
monly represented. If these labours were treated according to cor- 
rect principles, and at the proper time to make the principles avail- 
able, they would offer no difficulty beyond what is usually en- 
countered in turning, unless complicated by accident, (651.) But, 
if the favourable moment for acting be not taken advantage of, or 
should not have presented itself, much difficulty may be experienced ; 
and the case become subject to interference ; by cutting instru- 
ments, &c. 

1392. It should be constantly borne in mind, that the arm itself 
offers no indication of itself, save that of pointing out the position of 
the shoulder ; therefore, no manoeuvre performed upon it, can ad- 
vance the interests of either mother or child, or facilitate the object 
of the operator. Consequently, all the cruel, as well as absurd treat- 
ment to which the arm is sometimes subjected, such as scarification, 
amputation, &c, should always be avoided ; since it can never im- 
prove the process of turning, if the child be dead ; and it will almost 
necessarily destroy it, if living. 

the arrangements of Baudelocque, Meygrier, and Gardien — we shall therefore eon« 
tinue to adopt the order of Baudelocque, especially as none have improved upon his 
plan. Velpeau, we think extremely obscure in his directions for the management of 
" Shoulder presentations." 



PRESENTATION OF THE ARM AND SHOULDER. 435 

1393. In a well-formed pelvis, the presence of the arm offers no 
embarrassment to the operation of turning ; therefore, every attempt 
to remove it from the inferior portion of the pelvis, either by trying 
to replace it within the uterus, or by amputation, is only losing time, 
or improperly irritating the parts, or subjecting the protruded part to 
an unnecessary, and sometimes to a cruel operation. 

1394. There is no presentation that gives rise to so much bad 
practice, as the presentation of the arm ; for its mechanism is gene- 
rally but very ill understood. The arm itself is almost constantly sup- 
posed to offer great difficulties, by its presence in the vagina; hence, 
it has been scarified, twisted off, or amputated, to the disgrace of the 
profession.* It is true, that in most instances these severe operations 
have been performed after the supposed death of the child, but in 
many other cases we fear that the life of the child has not been taken 
into consideration, (1396.) 

1395. The death of the child should never be admitted with too 
much facility ; but especially, in the cases under consideration, as no 
operation upon the arm itself can ever increase the chance of gaining 
the feet. This should be w r ell recollected. Therefore, in arm pre- 
sentations, the amputation, or other operations upon it, should always 
be forbidden ; especially as the signs of death are in many instances 
as equivocal, as the evidences of life are obscure. 

1396. Chapman relates a most instructive lesson upon this sub- 
ject ; a lesson which should always be present to the mind of him, 
who may feel disposed to act in defiance of the best experience, by 
amputating the arm under the pretext that the child is dead. In the 
case alluded to, the accoucheur amputated the arm, on the presump- 
tion that it was dead ; it w T as, however, alive, and lived to manhood. 
And more recently, a surgeon was sued for amputating the protruded 
arms of a child from an expiring mother, and where it was not pos- 
sible to render assistance as he believed in any other way. The 
child, though supposed long dead proved to be alive. 

1397. It is, therefore, best not to meddle with the descended arm; 
for if turning be attempted, it offers no difficulty to the passage of the 
hand ; and if the crotchet, or any cutting instrument be resorted to, 
it cannot interfere with its operation. 

1398. The indication in these presentations is to bring down the 
feet, and deliver. It has, however, been suggested, that w T e may at- 
tempt the restoration of the head to the cavity of the superior strait, 
by removing the shoulder from it, I believe this to be altogether 
theory. I do not even advise the attempt ; for, independently of its 
difficulty, I am persuaded that it would be attended with more pain 
and risk to the patient, and injury to the child, than a well-conducted 
turning. 

1399. Mr. Barlow is of opinion that this is practicable: he says, 

* I never in my life subjected the arm to any discipline, though I have seen a good 
many cases of shoulder presentations ; both of my own, and more of other peopled 
treatment in the commencement. 



436 PRESENTATION OF THE ARM AND SHOULDER. 

" I come now to treat of that species of preternatural presentation 
where one or both arms present, and the head either resting on some 
part above the brim, or advanced along with either of the superior 
extremities into the pelvis. The mode of delivery sanctioned by 
authors in this division of presentation, appears involved in some de- 
gree of ambiguity ; for little variation of practice has been adopted, 
whether the presentation of the hand or hands at the brim of the 
pelvis, or that one or both arms descended low in the vagina, the 
same plan of delivery in every state, however dissimilar the case may 
be, seems to be invariably pursued. I conceive there requires much 
discrimination as well as variety of practice necessary to be adopted, 
according to different situations and stages in which the foetus is 
found to present under this distinction of preternatural presentation." 

1400. "If the accoucheur has the management of a case of this 
kind from the time of the discharge of the liquor amnii, and the hand 
of the child is ascertained to present, and the head canbe brought into 
the axis of the pelvis, it should be effected as early as the state of the 
os uteri will admit, and the reduction of the hand in this state of the 
case may frequently be accomplished by pushing it up and supporting 
it at the brim of the pelvis till the head becomes engaged in the supe- 
rior strait; if the other hand should protrude, it may be encountered 
by a similar expedient. If these attempts prove ineffectual, I would 
recommend the accoucheur to introduce a piece of sponge or other 
soft substance along the cavity of the pelvis during the absence of 
pain, and wedge or restrain the presenting hand or hands above the 
superior strait, till the head has cleared the brim of the pelvis. 

1401. On these directions it may be proper to remark, that when 
the arm or arms present, it can never be proper to attempt to bring 
the head of the child to " the axis of the pelvis," and for the follow- 
ing reasons : First, the arms cannot present before the membranes are 
ruptured; and after this the parts will have departed to some distance 
from the head ; and in proportion as they advance in the pelvis, will 
the head depart from " the axis of the pelvis." Secondly, it most 
frequently happens, that at the moment the arm has escaped from the 
orifice of the uterus, this part is no more dilated than is sufficient to 
permit the arm to pass ; or, if it has been more largely dilated, it will 
be found to have contracted itself so as to embrace the arm pretty 
strictly ; consequently, much force would be required to pass the 
hand into the uterus. Thirdly, that if the hand be made to pass the 
contracting os uteri, it will be found, that its operations, within the 
cavity of this organ, will be extremely limited, and by no means ad- 
equate to the reduction of the head. For every attempt to change its 
position will be opposed by the contracted uterus, which now, by 
virtue of its tonic power, accommodates itself to the various ine- 
qualities of the surface the child presents to it. Fourthly, if it were 
even possible to restore the head to " the axis of the superior strait," 
the arm or arms would accompany the head, and thus create great 
embarrassment to the progress of the labour, (718.) Fifthly, I be- 



PRESENTATION OF THE ARM AND SHOULDER. 437 

lieve it will be found the best practice, when we are under the ne- 
cessity of introducing the hand into the uterus in such cases, to finish 
the delivery by turning. 

1402. Mr. Barlow's directions respecting the attempt to return the 
arm or arms, I believe would be altogether unavailing, though as we 
have said elsewhere, (716,) that the hand very often may be pre- 
vented from prolapsing into the vagina, by supporting it until the 
head shall pass under it, but this can never be the case with the 
arms. It will be seen that Mr. B. has not made the necessary dis- 
tinctions between the hands accompanying the head, and the arm 
presentation;* for the latter always implies the exit of the arm from 
the os uteri ; while, in the former, the hands are enclosed in the ute- 
rus, or but very little advanced beyond the edge of its orifice. Now, 
there is an essential difference between these two conditions, and they 
require very different modes of treatment ; the directions of Mr. B. 
may answer very well when only the hands offer, but they would be 
totally inadequate for the restoration of the head. 

1403. When the arm accompanies the head, it is found that it 
almost always advances, pari passu, and it is true, that this circum- 
stance is not always subversive of the natural order of the labour. 
But this can only happen where the diameter of the head and arm 
do not exceed the diameter of the pelvis. See Section on the pre- 
sentation of the hand with the head, p. 253, par. 716, &c. 

1404. The circumstances which would render the restoration of 
the head to the axis of the pelvis practicable, (if it be practicable,) 
will also give facility to bringing down the feet; namely, a sufficient 
relaxation of the uterus, and the absence of pain. Moreover, if 
these conditions obtain in the first instance, it will, of course, be 
very uncertain whether the powers of the uterus will be suffi- 
ciently restored to expel the child after the adjustment of the head; 
consequently, much time might be lost, and much anxiety be created, 
and this for a success, that is altogether contingent. 

1405. There are three modes of proceeding in presentations of 
the arm ; the first, as I have just stated, is to turn ; the second, to 
trust to the powers of nature to produce what has been termed the 
" spontaneous evolution of the child," and the third, is the employ- 
ment of cutting instruments to the child itself. 

1406. When the arm presents in a labour at the full period of 
utero-gestation, we should entertain no hope or expectation that 
nature will relieve herself while the child continues in this position;! 
consequently, this case must be always regarded as "preternatural," 
and the bringing the child by the feet, is the only operation that can 
be performed with a view to the safety of both mother and child. 

1407. Notwithstanding the indication in this case is so obvious, 

* Mr. Barlow speaks of the presentation of both arms — a presentation we have never 
seen, though wc do not pretend, on this account, to deny sucli an occurrence. 

t Unless the rare occurrence of " spontaneous evolution" by a forced construction 
be considered an exception. 

38 



438 OF THE CONDITION OF THE UTERUS. 

yet it is not always practicable to fulfil it. This arises from — 1st, 
the condition of the uterus ; and 2dly, from the situation of the arm 
and shoulder within the pelvis. 



Sect. I. — Of the Condition of the Uterus* 

1408. I have already noticed above, (1392,) that the protruded 
arm or hand offers of itself no difficulty to turning ; the difficulty 
exclusively depends upon the condition of the uterus, and especially 
of that of its mouth. If both be in such a state of relaxation as will 
admit the passage of the hand without much force, (as often hap- 
pens soon after the escape of the waters, where the labour has pro- 
gressed regularly,) no more, or, perhaps, sometimes even less 
difficulty will be experienced, than in turning when the head pre- 
sents, and the uterus equally favourably disposed. 

1409. Our attention should, therefore, be constantly directed to 
the state of the uterus, and especially to that of its neck ; and our 
conduct should be regulated alone by their condition : for whatever 
may be our desire to aid the suffering woman, or relieve the 
threatened child, we must never incur the risk of being disappointed 
in both, by forcibly entering the resisting os uteri. When violence 
has been committed on this part by mechanically making it yield to 
the hand, inflammation, laceration, and gangrene have sometimes 
followed ; nor is this all : the operator has been foiled in his attempt 
to bring down the feet by the os uteri contracting itself around his 
wrist, and thus obstructing the descent of the child. I once wit- 
nessed death to follow immediately, or rather during a rude attempt 
to turn. The operator had with great difficulty passed her hand, 
(the patient was under the care of a midwife,) through the os uteri ; 
and after a long and uncertain search, became possessed of the 
feet ; in attempting to bring them down, she exerted so much force, 
as to rupture, (I believe,! the uterus. The poor woman expired in 

* Dr. Blundell's directions for the management of arm presentations are not only 
very obscure, but, in our estimation, very injudicious. He says, "I have frequently 
told you, that in ordinary cases, you should not interfere too soon ; but here is a kind 
of exception." Where you have a presentation of the shoulder and arm, and turning 
is obviously necessary, (is there any other method but turning t'»at can secure the 
delivery of the woman, and at the same time, preserve the child? We know of no 
other, nor do we know what is meant by " turning is obviously necessary" — for this is 
the only means ; "yet this only means," must be regulated by correct principles, or 
the object of the operation, as regards the child, most certainly, and, perhaps, the 
mother, will be defeated :) we are therefore, surprised that Dr. B. should make an ex- 
ception of " care and gentleness," in the case of arm presentation when both are so 
eminently required ; and rather surprised at the following advice : " The sooner you 
operate, the better; for, if you delay, the womb may contract, and without using great- 
force, the turning may be impracticable ! !" Read carefully what we say in this 
Chapter in Arm Presentation. 

t This belief is founded on what occurred during this attempt to turn ; namely, a 
slight hemorrhage from the vagina; sickness, and vomiting; cold clammy sweat, &.c. 
— of the pulse, I can say nothing; it was extinct when I saw the patient — the atten. 



OF THE CONDITION OF THE UTERUS. 439 

about five minutes after I entered the room, and while the midwife 
was still exerting all her force upon the legs of the child. The per- 
sons present informed me, that the midwife, after she had learnt I 
had been sent for, declared it was unnecessary, as she " could 
deliver the woman as well as any body" — she, therefore, redoubled 
her exertions, to make good her assertion : the consequences I have 
just related. She most industriously laboured in this attempt for 
more than an hour. 

1410. The midwife told me that iC the arm had been down many 
hours, and the pains were very strong;" but added, "notwith- 
standing this, the child did not come nearer the world ; I therefore 
determined to wait no longer, and proceeded to turn, as I had 
several times done in like cases. The mouth of the womb was 
close around the arm of the child; but I did not mind this; for I 
got first one finger in it, then another, and at last my whole hand. 
But indeed, doctor, this was hard work.* When I got through, I 
never was so long finding the feet ; but all my strength could not make 
them come down ; and the poor woman died, because I did not 
begin sooner.'' I took this poor ignorant creature aside, and frankly 
told her, she had destroyed her patient; and exacted, on pain of 
exposing her, a solemn promise, that she would never attempt the 
like operation again. 

1411. Therefore, when the mouth of the uterus strongly opposes 
the introduction of the hand, it should not be attempted ; in such a 
case, it will almost always be found if the waters have been long 
drained off, that the tonic contraction of the body and fundus, will 
also offer much difficulty to turning. This being the situation of 
the patient, nothing can justify the attempt to turn ; for one of the 
following consequences will almost certainly follow: 1st, If the 
hand be made to pass the stricture, it will be at the expense of so 
much injury to the neck of the uterus, that the one or other of the 
evils slated above will follow. 2d. If the hand be made to pass the 
constricting os uteri, the body and fundus will offer so much resis- 
tance, as to defeat the safe turning of the child ; or, 3d, If the child 
be safely delivered, it may be at the expense of the life of the mother. 

1412. It seems then to follow, that this condition of the os uteri, 
as well as of the body and fundus of this organ, must be changed 
before any attempt is made to bring down the feet of the child. 
With ihis in view, we must induce such a state of relaxation, as 
shall enable the hand to pass, and the turning to be performed, with- 
out the risk stated. This can be almost certainly effected, by a 
sufficient loss of blood. To exemplify the practice in such cases, I 
shall relate one, from my " Essay on the means of lessening Pain," 
&c, in which this remedy was successfully employed. 

dants, of course, could give no account of it, and the midwife was too much occupied 
by her operation to examine it. ' 

* This was a case of the inclined plane, spoken of at 673 et seq. The fundus of the 
uterus was larger lhan that of the body— this had contracted closely on the part offer- 
ing to it and made the inclined plane spoken of. 



440 SITUATION OF THE ARM AND SHOULDER 

1413. " 1802, January 29th, Phoebe Hall, a black woman, in 
labour with her seventh child; arm presented, and down for several 
hours; arm considerably swollen, as the midwife had exerted con- 
siderable force upon it ; the mouth of the uterus contracting closely 
round it. I got Dr. Carter, (a gentleman who accompanied me,) 
to introduce his hand into the vagina, and place a finger within the 
os uteri — this he did with some difficulty, as the uterus was very 
rigidly closed upon the arm. I tied up the patient's arm, to let her 
bleed until he should tell me the mouth of the uterus was sufficiently 
dilated. When I had drawn from forty to fifty ounces of blood, she 
became sick and faint ; at this instant Dr. Carter cried out with rap- 
ture that the uterus was sufficiently dilated — upon my examining, I 
found it to be the case; the turning and delivery were soon accom- 
plished." 

1414. It must be observed, that such labours as are attended with 
fever always require the loss of considerably more blood than when 
none attends ; and it has been found best, in such cases, to draw the 
blood at two or three operations ; but carrying the last to faintness, 
or at least to sickness of stomach. Now, the labours in question 
are almost always accompanied by fever, if they have been long 
protracted ; consequently, will frequently require the adoption of the 
plan just proposed. 



Sect. II. — Of the situation of the Arm and Shoulder vrithin the 

Pelvis. 

1415. The situation of the arm and shoulder within the pelvis, 
may be such as to render turning, if not impracticable, at least un- 
safe. 

1416. The arm, to the very shoulder, may be protruded through 
the os externum ; and the shoulder itself so unpacted, and the con- 
traction of the uterus so firm as to render it impossible to turn, with 
any prospect of success to the child, or safety to the mother. Our 
conduct, in this situation of things, must be regulated altogether by 
the condition of the child ; and this will be either living, or dead. 
It must therefore be ascertained in which of these states it may be, 
before we decide on the mode of acting. 

1417. With a view to determine this, the hand should be passed 
into the uterus until it reach the umbilical cord — if this pulsate, the 
child is of course living; if it do not pulsate, the child is certainly 
dead. 



a. The Manner of Acting, if the Child be Living. 

1418. Having ascertained the child to be living, our conduct 
should be such, as to give it the best possible chance to be delivered 



WITHIN' THE PELVIS. 441 

alive. The choice of means will lie between turning, and waiting 
for the spontaneous evolution of the child. As regards turning, it 
must not be disguised, that it is an operation of hazard to the child 
even under the most favourable circumstances of the uterus, or 
position of the child ; and of course, the risk will be in proportion 
to the departure' from these best conditions; yet it offers, in this 
case, almost the only alternative. 

1419. In the situations of the parts in the presentation now under 
consideration, two difficulties will necessarily present themselves: 
1st. The uterus will be found firmly contracted on the body of the 
child ; so much so, sometimes, as to render it almost impracticable 
to turn; or, at least, it would be hazardous, unless the operation be 
very carefully conducted. In such a case, it should not be attempted 
but with the utmost caution, and not without previously endeavouring 
to diminish the resistance of the fundus and body of the uterus by 
free blood-letting, as just proposed for the rigidity of the os uteri, 
when it creates a difficulty. After the patient has been liberally bled, 
the opposition to turning is sometimes so much diminished, as to 
render the operation not only practicable, but safe even to the child. 
Should the blood-letting procure no relaxation, the case becomes a 
forlorn one ; especially for the child. 

1420. We should not, however, for this reason, abandon the poor 
woman to her fate ; for even under a severe contraction of the uterus, 
a well-directed gentle force will sometimes overcome difficulties, that 
at first appeared insurmountable ; especially after a liberal dose of 
opium.* If the practitioner be inexperienced, he should, if possible, 
call to his aid a more skilled operator. He should never attempt to 
overcome by force, the difficulties which oppose him ; a proper 
exercise of patient address should ever govern in such cases, if he 
mean to succeed. 

1421. Secondly. In consequence of the firm contraction of the 
uterus, the shoulder, wz are, told, is found so tightly wedged in the 
inferior strait, as sometimes not to permit the slightest motion up- 
wards. I will not say, that this is never the case, but I must declare 
it seldom happens, unless the proper time for acting has been lost, 
either reprehensibly or unavoidably. {So far, I have never met w T ith 
a case, in which I could not turn, if turning were the desirable mode 
of acting : but this has arisen, perhaps from having been generally 
able to watch the proper moment for the operation.! 

* It will be borne in mind, that a free bleeding- must be performed, before the opium 
is given. The opium ehould be given in such doses as will ensure sleep. For this 
purpose I have been in the habit of giving two or three grains one, two or three hours 
until it procures rest; for if it tranquillizes by abating pain, the relaxation will follow. 
Of late Tartar Emttic has been substituted with advantage in such cases. See the 
Chap, on Convulsions. 

t I have made several admission << above, that would appear to contradict, what I 
here urge — the cause of these acknowledgments, is my respect for the experience, and 
opinions of others, though not borne out by my own practice. I say also, that I would 

38* 



442 SITUATION OF THE ARM, &C, 

1422. In these cases, the proper moment to act, is, so soon as the 
os uteri is sufficiently relaxed to permit the passage of the hand; and 
if this relaxation do not take place spontaneously, it should be pro- 
cured as early as the nature of things will permit, by blood-letting 
and opium ; and this as soon after the escape of the waters as prac- 
ticable. If the case have been mismanaged, before a judicious 
practitioner has been consulted, he may not perhaps be able to termi- 
nate the labour by turning, with any prospect of success to the child ; 
he is then to consult the interest of the mother alone ; and this will 
perhaps be best advanced by waiting, so long as the child may con- 
tinue to live. 

1423. But should any accident complicate the labour, and render 
immediate delivery proper, he should try to relieve the patient by 
turning, though it offer but a bad chance for the preservation of the 
child. If this be impracticable, (a circumstance, I am warranted in 
saying, of rare occurrence,) he must relieve the mother at the expense 
of the child, as will be directed presently. 

1424. The only other resource which presents itself for the pre- 
servation of the child, is waiting for what is termed the " spontaneous 
evolution of the child.'* 



b. Of Spontaneous Evolution. 

1425. Schneider was the first to notice this change in the pre- 
sentation of the foetus, but Dr. Denman was the first to notice this 
remarkable resource of nature, in shoulder or arm presentations. He 
enriched the profession by his history of it, and by instructing the 
practitioner, that in some instances, nature achieves with even safety 
to the child, that which art could not have performed. His explana- 
tion of this phenomenon is highly ingenious, and was for a long time 
the received one ; but it appears to have yielded to that of Dr. 
Douglass, even by the confession of Dr. Denman himself. See Dr. 
Douglass's Essay on Spontaneous Evolution. There is a case lately- 
recorded, where the child was delivered by the right foot, by the 
unaided efforts of the uterus; it is thus related in the " Bulletin des 
Scien. Med." for July, 1830, page 95, from Siebold's Journal fur 
Gebartzhulfe, etc. T. viii. 3d cap. p. 712. 

Dr. Schneider was called to a woman on the 13th of July, 1822. 
He was informed, that the child had presented the arm, and that the 
delivery was effected by the powers of the uterus alone. The people 
present could not inform him how the thing happened ; but the patient 
declared, that the waters were discharged by the first pains, and that 
an arm of the child immediately fell into the vagina. The woman in- 

tum when turning was the desirable mode of operation— meaning by this, thnt there 
are exceptions to this rule: see par. \4&7; also, the at tide on turning in deformity of 
the pelvis. 



WITHIN THE PELVIS. 443 

stantly sent for help, but in a few minutes after, violent and almost 
insupportable pains came on, during which time the woman felt as if 
the whole abdomen was turned upside down, (bouleverse.) Very 
soon after the right foot of the child escaped, and then the trunk and 
head. The right arm of the child was livid and swollen, proving, 
that this part first presented itself. The child was of middling size, 
but dead. The pelvis of the woman was very large. 

1426. This chance for the preservation of the child, is, however, 
of extremely rare occurrence ; for in by far the greater number of in- 
stances of " spontaneous evolution," the child has been expelled dead. 
Indeed, the delivery of the woman by this change of position of the 
child, is in itself very rare. I have never seen a case. Yet the tes- 
timony on this point is conclusive, and will justify us in considering 
it a resource, after all the rational endeavours have failed, yet it must 
be evident the change sometimes so fortunate for both mother and 
child, can only reasonably be expected, when the child is small or 
the pelvis very ample. 

1427. I say, a chance for the child ; for such only should it be 
considered ; for if the child be dead, we have no longer terms to keep 
with it ; our attention must be solely directed to the safety of the mo- 
ther. I should, therefore, recommend waiting for this " spontaneous 
evolution," whenever turning forbad the hope of saving the child, 
provided the labour be not complicated by either of the accidents 
enumerated, (651 ;) but if the child be dead, and this ascertained as 
directed,* (1417,) we should not wait for the uncertain event of 
' ; spontaneous evolution." 

The following case occurred to us : — The patient was a robust, 
healthy primipara setat 28. — The membranes had ruptured with the 
first pains, and an arm prolapsed. Xo assistance was requested for 
two days, when two midwives tried to turn, but did not succeed. — 
The pains were violent and the author was summoned. He found 
the patient suffering under incessant and painful uterine contractions, 
without a moment's cessation. The skin was hot, the pulse small and 
hard, the patient pale and exhausted. The arm (the left) was im- 
mensely swollen, livid and- black, and the epidermis pulled ofT. The 
labia and vagina were much swollen and were beginning to dry. The 
author made an attempt to turn, but could not succeed ; he therefore 
bled her, and used narcotics both inwardly and outwardly, by which 
means the pains in the loins and abdomen abated ; she became quiet 
and fell into a sound sleep which lasted from five to six hours, during 
which she perspired freely. — Slight contractions of the uterus and 
almost without pain now came on ; and by their action the arm and 
shoulder descended still farther, while at the same time the left side 
of the thorax began to press downwards from the sacrum towards the 
left arm ; the hip followed the side of the trunk, and as the child 

* It must be recollected, we can pass the hand to the umbilicus of the child when 
it might be impracticable to turn. 



444 SITUATION OF THE ARM, &C, 

turned completely round the nates followed, and together with the 
trunk and legs were now expelled. The head with the arm stretched 
along it followed without any difficulty, as also did the placenta. The 
whole process lasted only a few minutes, and the patient assured the 
author that she had scarcely felt any thing of the pain. — The child 
which was dead was full grown : it was emphysematous ; the-epider- 
mis peeling off and the limbs quite flaccid. It was to this state of 
perfect flaccidity, the result of incipient decomposition, that the pa- 
tient was indebted for the perfect ease with which the whole was 
accomplished. 

1428. Dr. Merriman has very properly observed, " the occurrence 
of the spontaneous evolution has been comparatively so rare, that no 
man would be justifiable in simply relying on it. The knowledge that 
it has sometimes happened, may, indeed, under some circumstances 
of extreme resistance to the passage of the hand into the uterus, re- 
concile us to the delay which I have recommended; but we should 
never allow it to operate upon our minds, so as to induce us to neglect 
the proper means, and proper time of turning ; when we have it in 
our power. It is the duty of the accoucheur, on all occasions, to give 
nature every possible opportunity of exerting herself for the relief of 
the patient; but it is equally his duty, when nature becomes embar- 
rassed and oppressed, to interpose the timely assistance of art ; lest 
nature, being compelled to relinquish the task, the patient fall a sacri- 
fice to the delay."* 



c. Mode of Meting, if the Child be Dead. 

1429. If it be ascertained that the child is dead, and it should be 
impracticable to turn, we must attempt the delivery of the child, by 
the use of instruments. The instruments necessary for this purpose, 
may be, the scissors, and crotchet, or simply the blunt hook. Before, 
however, either is employed, the uterus should be either dilated, or 
dilatable ; and this will almost always be found to be the case, where 
the shoulder is forced down to the os externum. 

1430. In this situation, we can always command the thorax or 
abdomen of the child ; either of which may be penetrated by the 
scissors : and these aided by the crotchet, or blunt hook. It has 
been recommended by several, to bring down the head by pulling 
with a blunt hook fixed over the neck. It would seem, that this 
plan was first suggested by Celsus ; it is, however, claimed for one 
Home by Heister, as an original invention. When the shoulder 
has really been thrust without the os externum, and the child certainly 
dead, it may become a question, which of the two propositions will 
be most easy to fulfil. Dr. Sims has successfully used the blunt 
hook upon the neck of the child in at least two cases ; in one, the 

* Synopsis. 



WITHIN THE PELVIS. 445 

head was delivered without separating it from the neck ; the other 
was attended by this separation. In both instances, the child had 
been dead a long time. I can say nothing from experience, on 
either of these modes ; therefore will not decide positively on their 
comparative merits ; it nevertheless strikes me, that the one, which 
will be attended with the least risk of violence to the soft parts of 
the mother, should be preferred ; and this appears to be the one, 
which will diminish the child's bulk before it is forcibly dragged 
from the mother's pelvis; therefore, perhaps, the scissors and 
crotchet, may be the safer method in this respect. 

1431. It has been usual, it would seem, in cases where turning 
was impracticable, to wait for the " spontaneous evolution" to take 
place ; but I would not recommend this plan, when it is certain the 
child is dead; and for these reasons: 1st. This evolution is not 
certain to take place ; 2d. If it do not, we certainly expose the wo- 
man to much suffering; and, perhaps, even to danger, for the hope 
of this favourable contingency, (1417.) The British practitioners 
being much more familiar with these untoward cases of arm pre- 
sentations, do not hesitate to operate with cutting instruments upon 
the child. We will, therefore, give a part of Dr. Leed's mode of 
proceeding in such cases. 

"On the 15th of October, 1824, I was called to visit a patient of 
the Westminster General Dispensary, residing in Great St. Andrew 
Street. I found her in the following condition. The membranes 
had been ruptured fourteen hours, and the liquor amnii had entirely 
escaped. The right arm, much swollen and livid, was protruding 
out of the external parts, and the shoulder and part of the thorax 
were firmly impacted in the pelvis, while the contractions of the 
uterus were violent and incessant. The pulse was quick, the face 
flushed, and the soft parts lining the pelvis were hot, dry, and very 
tender. Thirty ounces of blood were drawn from the arm, and sixty 
drops of laudanum administered before any attempt was made to 
alter the position of the child. After waiting for half an hour, 
when the pains had somewhat diminished in violence, I attempted 
slowly to pass up my hand, but the pains were immediately re- 
newed with redoubled force ; and after persevering for upwards of 
an hour to turn, I was compelled to abandon the intention. Ano- 
ther practitioner then saw her, when other twenty ounces of blood 
were drawn from the arm, and forty drops of laudanum were ad- 
ministered. He waited some time in the hope that the actions of 
the uterus would cease : but this not taking place, he proceeded to 
endeavour to pass up his hand into the womb. This attempt again 
excited the most violent bearing down pains, and after long and 
fruitless exertions, he was also compelled to desist from the threat- 
ning danger of rupture of the uterus. 

11 Two hours having elapsed after this second attempt to turn, 
and the pains still continuing undiminished, I separated the arm 
from the body at the shoulder joint, laid open the thorax by the 



446 SITUATION OF THE ARM, &C, 

means of the crotchet, and passing it through the opening thus made, 
fixed it on the lower part of the spine; and on dragging down with 
a steady force, the child passed out of the external parts doubled. 
Though there was a great distention of the parts at the outlet of 
the pelvis, no laceration of these took place. 

" The superior aperture of the pelvis having been considerably 
under the ordinary dimensions, some resistance was offered to the 
passage of the head ; but this was overcome without much difficulty. 
The patient speedily recovered, and has since been delivered by 
me of an eight months' child, where the breech presented, and 
where the life of the child was lost, from the time and force required 
to bring the head through the confined brim of the pelvis. 

"On the 1st May, 1827, I was requested to visit Mrs. Kagen, 
Charles's Street, Drury lane, also a patient of the Westminster 
General Dispensary. She had been two days and nights in labour, 
and was extremely exhausted with fatigue. The left arm much 
swollen was presenting, and around it a loop of the umbilical cord, 
which did not pulsate. There was great thirst and restlessness, and 
the abdomen was tense and very painful on pressure. The pulse 
was extremely quick. The uterus was contracting with great force, 
and I found it quite impracticable to pass up the hand, or to push 
back the. presenting part, so firmly was it impacted on the pelvis. 
Sixteen ounces of blood were drawn from the arm, and an opiate 
administered at 4 A. M. At 7 o'clock the pains had almost ceased, 
but were instantly renewed on attempting to turn. The child being 
dead, I did not persevere long in my efforts to turn, but delivered 
without much difficulty in the manner already described. Here, 
also, there was contraction of the brim of the pelvis, of which a 
lamentable proof existed in a fistulous opening between the bladder 
and the vagina, reported to have been caused some years before by 
a protracted labour, which was terminated by the use of the forceps. 

" On the 14th May, 1827, I was called to a patient of the same 
Institution, in King Street, Drury lane. The left arm presented, and 
the shoulder and thorax were forced deeply into the pelvis. The 
umbilical cord was hanging without the external parts, and did not 
pulsate. The contractions of the uterus were strong, and were much 
increased on attempting to introduce the hand. The delivery was 
accomplished with the utmost ease, and in a very short time, as 
already described. The extraction of the child was effected very 
slowly, to allow of the dilatation of internal parts, and to prevent 
laceration of the perinaeum. On the second day after delivery, this 
patient experienced a slight attack of abdominal inflammation, which 
readily yielded to one copious bleeding and cathartics. 

" In another case which has since occurred to me, and which in all 
essential circumstances resembled the three now detailed, the same 
method of accomplishing delivery was adopted, and with similar 
success. 

" I do not consider it necessary to define more clearly the cases to 



WITHIN THE PELVIS. 447 

which the above practice ought to be applied, as it is hardly possible 
for any one, after the observations I have made, to misunderstand the 
object of this communication, or to suppose that the common ope- 
ration of turning should be abandoned where there is a reasonable 
hope of saving the child's life, and that of the mother. 

" The method of effecting delivery above mentioned, I was led to 
adopt, from reflecting what takes place in cases of spontaneous evo- 
lution of the foetus ; and it may be perceived, that in all the foregoing 
instances nature had begun, and was striving, though ineffectually, 
to complete this process. 

" Since the occurrence of these cases, I have had an opportunity 
of perusing the essay of Dr. Douglass on this subject, and have 
been gratified to find he has recommended the same mode of treat- 
ment, and has been also forcibly impressed with the impropriety of 
turning in all cases of arm presentations. Dr. Sims, in the fortieth 
volume of the medical and Physical Journal, stated similar views, 
but did not lay down any specific rule of practice in such embarrass- 
ing cases. 

" Dr. Davis, in his Elements of Operative Midwifery, p. 326, 
concludes some observations on this subject with the following words. 
1 If, therefore, we suppose the child to be already dead, or the 
circumstances of the labour to be such as to make it impracticable 
to bring it into the world alive by means of turning, or even to per- 
form that important operation at all without exposing the mother to 
extreme danger, it would then, in my opinion, be the unquestionable 
duty of the practitioner to effect the delivery by embryotomy.' 

" Instead of extracting the child double, he recommends ' that it 
should be divided into two principal parts, head and body, by pass- 
ing a properly adapted cutting instrument across, and through the en- 
tire structure of the neck ;' and he has delineated in his invaluable 
work instruments for this purpose. 

" Notwithstanding, however, his ingenious invention of craniotomy 
forceps, and of the power which they confer upon us of extracting 
the head, or any other part of the child from the uterus, still I should 
be disposed to avoid, if possible, the occurrence of the head remain- 
ing in the cavity of the uterus after the extraction of the body, as it 
must be extremely difficult to find afterwards for perforation, and 
quite impossible to accommodate it to the diameters of the pelvis in 
passing. 

" The difficulty of reaching the neck when the shoulder and thorax 
are thrust deep into the pelvis, and the head of the child is tilted up 
over its brim, appeared to me in the preceding cases so great as to 
be almost insuperable, setting aside the disagreeable process of pass- 
ing up cutting instruments so high within the uterus." Dr. Rams- 
botham describes this operation (of Exviceration as he terms it,) in 
the following words : " The woman lying on her left side ; an assis- 
tant should be directed to bring the chest as fully into the pelvis, by 
traction at the arm, as possible ; the perforating scissors, guided by 



448 FALLING DOWN OF THE UMBILICAL CORD. 

two fingers of the left hand, should be carried against one of the in- 
tercostal spaces, and a free opening made. One or more ribs might 
be divided, if necessary, so that two or three fingers, or the whole 
hand, might be introduced within the aperture. Through this inci- 
sion, the contents of the foetal thorax must be extracted ; the dia- 
phragm may be perforated afterwards, and by the same opening the 
liver and intestines evacuated. The body thus deprived of the prin- 
cipal part of its contents, will collapse, and if the uterus continue to 
act with vigour, will be expelled double, the breech sweeping the 
sacrum and perinceum. But, should the pains have ceased, artifi- 
cial extraction may be most beneficially made by means of the crotchet 
fixed within the foetal ilium,the breech will soon be observed to de- 
scend, and the case will terminate as though nature had expelled the 
child unaided." 



CHAPTER XXXVIII. 



ON PRESENTATIONS, WITH THE FALLING DOWN OF THE UMBILICAL 

CORD. 

1432. We have already expressed our surprise, that the cord does 
not more frequently accompany the presenting part, and by its presence 
embarrass the labour, than it is found to do. Yet a prolapsus of the 
cord is comparatively, and fortunately of rare occurrence. 

1433. It will readily occur, that a labour complicated with the de- 
scent of the cord, can only be threatening to the child ; since the 
cord being down cannot of itself interfere with the mechanism of a 
labour, or influence its duration ; consequently, can offer no threat to 
the mother. It is then the safety of the child alone, that claims our 
attention, or that presents us with any specific indication ; for on its 
welfare we must base all our rules of conduct. For, if the child be 
dead, and this can be determined by the want of pulsation in the 
cord, the funis being down, should not alone make us interfere with 
the labour. For Dr. Denman has very justly observed, " It is only 
when the child is living, that any interposition can be required, or be 
of service ; yet it is remarkable that writers on this subject have in- 
stituted their directions in general terms with regard to the state of the 
child, whether living or dead." 

1434. We may sometimes determine, that the cord will prolapse, 
even before the membranes have given way ; for it may sometimes be 
felt, either single or in folds, immediately before the presenting part. 
Its peculiar form, and its pulsations, can be perceived behind the 
membranes in the absence of pain, if the finger be placed against 



FALLING DOWN OF THE UMBILICAL CORD. 449 

them, and the os uteri be sufficiently open : and this at once decides 
the nature of the case. When this happens, it may be looked upon 
as an important warning, as it directs us to a peculiar observance in 
practice ; but if it only declare itself after the rupture of the mem- 
branes, by falling into the vagina, we necessarily lose the advantage, 
that a previous knowledge that this was about to take place, would 
give us. 

1435. Some have attributed this accident to the uterus being un- 
usually loaded with the liquor amnii ; but we believe without sufficient 
reason ; for we have seen most abundant flows of this fluid unattended 
by this accident ; and we have certainly witnessed it, where the quan- 
tity- was not uncommonly great. Others have ascribed it to an un- 
usual length of cord ; this is more probable, since, it is presumable, 
that this circumstance would increase the liability to the accident, 
though, perhaps, it may not be essential to it : we may at all events 
most safely affirm, that we have seen cords of great length where this 
protrusion did not take place. 

1436. Perhaps it may be truly said, that this event is altogether 
accidental, or contingent; though Dr. Denman declares that some 
women appear more liable to it than others : it would certainly be 
difficult, were this even the fact, to determine in what the predisposi- 
tion consists, as it does not seem to depend upon either the quantity 
of liquor amnii or the length of the cord. 

1437. I have said, that the circumstance of the cord preceding the 
presenting part of the child, is altogether, perhaps, accidental, or con- 
tingent. I believe this to be the case, from the difficulty of assigning 
'he predisposing causes, as just observed, and the extreme rarity of 
the occurrence. I am of opinion, that when this happens, the fol- 
lowing circumstances must take place : first, that the cord must be 
precipitated before the presenting part, and made to rest against the 
membranes ; in this case the prolapsing of the cord would be inevita- 
ble ; and the cause of this situation of the cord, must be hidden, 
perhaps, in the same obscurity, as any other deviation in the presen- 
tation of the child itself. Secondly, that if the cord should not origi- 
nally offer with the presenting part, then two circumstances must ob- 
tain, that the floating cord may be carried without the os uteri ; and 
these appear to be, first a small, but powerful current instead of the 
diffused and feeble discharge of the liquor amnii ; and secondly, that 
this current must meet in its course, a portion of the cord sufficiently 
long and disengaged, to be carried by it without the uterus. If it be 
asked, how can this partial current be established, and endowed with 
an adequate power to produce the accident in question ? I would 
answer, by the head or presenting part of the child occupying the su- 
perior strait so strictly, as to prevent the escape of the waters, but 
from a small portion of that opening ; and the force with which the 
liquor amnii shall escape, will necessarily be commensurate with the 
power with which it is urged ; or, in other words, it will be driven 
with an impetus, equal to the force with which the uterus contracts. 

39 



450 



ON PRESENTATIONS, WITH THE 



1438. We need but insist, in confirmation of this conjecture, that 
the presenting part every now and then does so completely occupy 
the superior strait, as to dam the waters above it, and thus create dif- 
ficulty and delay in the labour ; hence the direction to raise the head, 
that the waters may escape. 

1439. But a truce with conjecture ; itjs enough for all practical 
purposes, (since, did we know the cause, we could not prevent the 
effect,) that the cord does precede the presenting part ; and that under 
two circumstances, as we have just stated. It is proper to observe, 
however, that each condition in which the cord may prolapse,* requires 
some difference of management. 

1440. We will first notice the cases in which the presence of the 
cord is detected, before the waters have escaped. 

1441. It almost supposes theos uteri to be opened to some extent, 
when we are able to detect the presentation of the cord, since it 
requires some space to ascertain satisfactorily its presence ; at least with 
sufficient certainty to make us determine on one mode of proceeding, 
in preference to another. 

1442. We are directed in such cases, both by Dr. Denman and 
Mr. Burns, if the cord prolapse, and the os uteri be but little opened, 
rather to wait the issue of the natural progress of the labour, than to 
forcibly enter the uterus ; in this, we perfectly agree. But Mr. Burns, 
immediately after advises, "as soon as the os uteri will admit the 
introduction of the hand, the child should be turned, if it can be 
easily done." And Dr. Denman seems inclined to the same mode 
of treatment, though a little more precise, and more guarded upon 
this subject than Mr. Burns ; but both are advocates under certain 
restrictions, for turning. 

1443. Mr. Burns declares the sum of practice in this case to be, 
1st, that " when the os uteri is not dilated, so as to permit turning, 
we must not attempt it ; but when turning is practicable, it is to be 
performed ; 2dly, when the head has descended into the pelvis, the 
cord is to be replaced ; 3dly, or secured as much as possible from 
pressure ; 4thly, but if the circulation be impeded, the woman must 
be encouraged to accelerate the labour by bearing down, or instru- 
ments must be employed ; 5thly, when the presentation is preterna- 
tural, these directions are to be attended to, and the practice is also 
to be regulated by the general rules applicable to such labours." 

1444. We shall examine each of these directions in order, and, 
1st, that " w r hen the os uteri is not dilated, so as to permit of turning, 
we must not attempt it; when turning is practicable, it is to be per- 
formed." Dr. Denman more cautiously advises, "if the child be 
living, and the presenting part high up in the pelvis, especially if the 
pains have been slow and feeble, it will generally be better to pass 
the hand into the uterus, to turn and deliver the child by the feet ; 
using, at the same time, the precaution of carrying up the descended 
funis, that it may be out of the way of compression." But, notwith- 
standing these positive directions, I am inclined to think that the 



FALLING DOWN OF THE UMBILICAL CORD. 451 

question to be solved in such cases is, 1st, whether it be ever proper 
to turn for the mere presence of the cord ; and, 2dly, if it be, what 
are the circumstances which render it so ? 

1445. Turning must always be looked upon as of doubtful safety 
to the child, (736 ;) its adoption must, therefore, be constantly re- 
garded as a choice of evils. In a case of prolapsed funis, it should 
be resorted to with great caution, especially as there is no question 
that children are frequently born alive after the cord has been pro- 
lapsed, and when the progress and termination of the labour was 
confided to the natural powers. While, on the contrary, the fact is 
equally well established, that they have perished during the extraction ; 
and I believe, we may safely say with Baudelocque, " and all this in 
cases where they might have been born alive, notwithstanding the 
exit of the cord, had the delivery been left to nature." 

1446. " For," adds he, " after the discharge of the waters which 
brought it (the cord) out, the expulsion of the child is often quicker 
than its extraction could be ;" therefore, " we should, in all such 
cases, add a long compression of the cord, to the danger sometimes 
inseparable from turning the child, and bringing it by the feet." 

1447. Now as it is admitted, that children have been born alive, 
when nature has not been interfered with, though the funis had pre- 
sented, it follows that this part, in such cases, does not necessarily 
suffer compression; consequently, turning, as a general practice, 
should not be inculcated, especially as we can often avert this 
dreaded pressure, by carrying the cord to that side of the pelvis to 
which it may most incline ; or by restoring the funis within the uterus, 
beyond the risk of this accident. 

1448. Turning can only be considered as the better means, when 
no farther reliance can be placed on the powers of nature to effect 
the delivery in proper time ; or, when the cord suffers either con- 
stant or occasional compression ; either of which, if continued beyond 
a certain time, will inevitably destroy the child. It is not sufficient 
because the pains are feeble and long in returning, to make us con- 
clude that the powers of nature are incompetent to the end, and 
make us resort to the doubtful expedient of turning; for, unless the 
cord be threatened with compression at the same time, the mere tar- 
diness of labour, especially at the earlier part of it, offers no imme- 
diate indication. 

1449. For we may, in many cases, urge the reluctant powers of 
the uterus to proper and efficient action, or restore them when they 
have flawed from exhaustion. The first is sometimes succesfully 
accomplished by bleeding, a stimulating injection, or by opium; the 
latter, oftentimes most happily, by the secale cornutum. 

1450. It may, however, be necessary to turn, or otherwise treat 
this case, if it be complicated by other accident; but the propriety 
and nature of the choice must be governed by the nature and force of 
the additional complaint. Or it may become absolutely necessary to 
turn, if the presentation be preternatural, agreeably to our accepta- 



452 ON PRESENTATIONS, WITH THE 

tion of the term, (615 ;) and often highly expedient, at least to inter- 
fere with the regular course of the labour, when either the breech, 
feet, or knees, shall offer. Thus, if the breech, feet, or knees, pre- 
sent, it may become necessary for the preservation of the child, to 
bring down the feet, and finish the labour by artificial aid. 

1451. It should, however, constantly be borne in mind that even 
when we determine on this operation, it should be subject to all the 
regulations we have already imposed upon it. See Chapter " On 
Turning." 

1452. When we have ascertained that the funis is below the pre- 
senting part, I would depart from the rule I have laid down, (544,) 
of rupturing the membranes : I would, in this case, preserve them 
with the most scrupulous care, by not " touching," by strict rest on 
the part of the patient ; and cautioning her against bearing down. 
By these means we may prevent the yielding of the membranes until 
the last period of labour ; and of course, prevent the compression of 
the cord. I do not know that this plan has hitherto been recom- 
mended : though so obviously important when it can be complied 
with. I can, however, only speak of its utility, in a single case. I 
ascertained, in the early part of a certain labour, that the cord was 
presenting ; and made up my mind not even to touch my patient until 
the pains should declare the last period to be at hand. Upon exami- 
nation, at the time I thought proper, I found the membranes ready to 
protrude the os externum ; and, in which, I could distinctly feel the 
prolapsed and pulsating funis. The head of the child was about to 
emerge from under the pubes ; and the soft parts pliant, and every 
way disposed to yield. I now ruptured the membranes, and the 
head and body almost immediately followed the discharge of the wa- 
ters. The child was healthy, and cried lustily. 

1453. I do not wish more consequence to attach to this plan than 
it deserves ; for I must confess it is no direct evidence, that the 
safety of the child depended upon maintaining the integrity of the 
membranes, to so late a period ; as we know that the same happy re- 
sults have followed delivery in cases of the falling of the cord with- 
out this precaution having been observed. Yet, one thing is nearly 
certain ; that the funis cannot be either very long, or very severely 
compressed, so long as it is retained within the entire membranes. 
This plan would be particularly important with a first child ; or where 
the uterus opens reluctantly ; or where the labour progressed slowly, 
and the external parts offer much resistance. It must, however, be 
granted, that it cannot always be earried into execution, as there are 
several causes which may rupture the membranes besides design ; 
yet, nevertheless, when it can be done, we think it should be done. 

1454. 2d. w When the head has descended into the pelvis," says 
Mr. Burns, " the cord is to be replaced, or secured as much as pos- 
sible against pressure ; but if the circulation be impeded, the woman 
must be encouraged to accelerate the labour by bearing down, or in- 
struments must be employed." 



FALLING DOWN OF THE UMBILICAL CORD. 453 

1455. This rule necessarily divides itself into several very impor- 
tant ill-defined directions ; it will T therefore, be necessary to its in- 
vestigation, that we consider them separately. 

1456. First, " When the head has descended into the pelvis, the 
cord is to be replaced." This direction has always been a great de- 
sideratum in the treatment of labours complicated by the presence of 
the cord, and various plans have been suggested by several ingenious 
and experienced members of the profession, neither of which, how- 
ever, has been very successful. The crutch of Burton, the leathern 
purse of Mackensie, the attempt at its suspension of Croft, have been 
alike unrewarded by success. 

1457. A more plausible method has lately been suggested by Dr. 
Dudan, which, he says, has been crowned with success in the in- 
stance in which it was tried. He proposes " to carry the prolapsed 
portion of the funis into the uterus by means of a gum elastic male 
catheter and ligature, in the manner following : — The catheter should 
be of the size of No. 8 or 9, with its stilet ; a piece of narrow riband, or 
several thicknesses of strong thread of sufficient length, well waxed, 
must be introduced into the last eye of the catheter, and retained 
there by the extremity of the stilet. The cord must now be attached 
by the riband encircling it, without drawing it too tight. If the loop 
of the cord be short, or not more than seven or eight inches, it may 
be tied in the middle ; but, if longer, it should be doubled, and tied 
towards the centre of the fold. 

1458. " The cord must be returned within the uterus atone of the 
sides of the pelvis; if it be carried to the right side, the right hand 
should be used ; if to the left, the left hand, making the opposite 
hand serve as the guide to pass it between the head of the child and 
the neck of the uterus. As soon as the loop is found to penetrate 
between the head and uterus, it should be pushed with considerable 
force ; and without our having fears, we may stop the circulation 
within the cord ; or, should it be interrupted for a short time, it is of 
no consequence. At the same time, with the hand which serves as 
a guide, we may assist the passage of the cord within the uterus, 
and at the same time prevent its slipping into the loop of the riband. 

1459. " When the cord is returned, we need be in no haste to 
withdraw the catheter; on the contrary, we should wait until the pains 
have made the head of the child engage in the superior strait ; when 
it acts, if it may be so expressed, as a cork. Then the stilet must be 
withdrawn, and the catheter can easily be made to follow. The riband 
may remain, as it will be expelled with the child." 

14G0. This project I believe to be better than any other hitherto 
proposed, as it gives more entire command of the prolapsed cord, and 
by a means which cannot injure either mother or child. This plan so 
nearly resembles one I proposed some years ago, that they might well 
pass for the same. But that of Dr. Dudan is in one respect a consi- 
derable improvement on that of mine, by substituting the flexible male 
catheter for a piece of plain steel of proper size with an eye to it, as 



454 ON PRESENTATIONS, WITH THE 

I had proposed ; while that of mine has, perhaps, an advantage in the 
mode of applying the riband, or ligature. 

1461. In Dr. Dudan's plan, which, by the by, he describes very 
ill, the riband is tied over the cord with sufficient tightness, and the 
ends are passed through the eye of the catheter, and fastened within 
the canal by pushing up the stilet; while, in my method, the riband 
is passed round the cord without tying; the ends are then passed 
through the eyes by withdrawing the stilet sufficiently to leave them 
clear ; the extremities of the riband are then drawn sufficiently tight 
to place the cord and catheter in contact. The advantage of this 
method is, that we can always regulate the degree of compression upon 
the cord ; or we may take it off altogether if desirable ; whereas, in 
the other, it must always remain the same. 

1462. As these plans are rather difficult to comprehend from de- 
scription, I have added drawings by way of illustration. It will be 
seen that I have availed myself of Dr. Dudan's suggestion of the 
flexible catheter. See plate XVII. , and explanation. But to 
proceed. 

1463. 3d. " Or secured as much as possible from compression:" 
to do this, we are directed by almost all the writers upon this subject, 
to carry the cord to one of the sides of the pelvis, and the side nearest 
to the prolapsed portion is always the best. We can sometimes 
succeed for a time in preventing the compression of the cord by this 
plan, but it will be readily understood that this cannot be permanent, 
as the head, in changing its position to place itself under the arch of 
the pubes, will press upon it with more or less force and certainty. 
The child will now be in great jeopardy, and if not very speedily de- 
livered will die. The woman should be solicited to aid herself as 
much as possible, or the ergot should be given, with a view to hasten 
the labour. 

1464. 4th. "But if the circulation be impeded, the woman must be 
encouraged to accelerate the labour by bearing down, or instruments 
must be employed." 

1465. This direction is more vague, perhaps, than any of the pre- 
ceding ; it runs counter in its tendency, if literally interpreted, to the 
advice of the most respectable authorities upon this subject ; for, if 
the circulation be arrested, the child will certainly die in the course 
of a very few minutes ; and if the circulation have been stopped suffi- 
ciently long to cause the death of the child, it is agreed upon all hands, 
and even by Mr. B. himself, the labour should not be meddled with, 
as it would be unavailing to do so ; consequently, the woman need 
not be urged to unusual exertion, nor should instruments, or any other 
artificial means be thought of. 

1466. It is by no means uncommon for the life of the child to be 
threatened in a case- of the prolapsus of the cord, when the head is low 
in the pelvis ; as there is a constant liability to its being placed between 
the head and the pelvis, and thus suffer more or less compression; 
we have already provided for this condition, (1449,) when delivery 



FALLING DOWN OF THE UMBILICAL CORD. 455 

can be performed in time to save the child, by the exertion of the 
woman, or by increasing the power of the uterus by the exhibition of' 
the " ergot :" or if the forceps can be commanded in time, they may 
sometimes be advantageously employed. 

1467. Now, Mr. Burns vaguely prescribes the use of "instru- 
ments;" the choice of a proper one might embarrass a young practi- 
tioner; though we are disposed to admit that Mr. B. would select for 
his own use, either the forceps or the vectis, for he had just said so; 
as the object unquestionably should be to save the child's life : but 
this should surely have been again designated, especially as he is now 
posting up the points of practice. Moreover, it appears to give con- 
tradiction to the cautions and distinctions he had just made before, 
and thus sets him against himself. For, just above, he states : " If 
this be not practicable," (returning the cord,) u and the pulsation 
suffer, or the circulation be endangered, we must accelerate the labour 
by the forceps. If the pulsation be stopped, and the child dead when 
we examine, then labour may be allowed to go on, without paying 
any attention to the cord," p. 404. Yet, a few lines below, we find 
the ambiguous directions we have just quoted. Dr. Denman is much 
more precise upon this subject ; he observes, that " when the head of 
the child presents, and has advanced far into the pelvis, if the pains 
be slow, and ineffectual, and the child living, it may be considered 
whether, without hazard to the mother, we may not employ the for- 
ceps or vectis ; and by extracting the head sooner, than there was reason 
to think it would be expelled by natural pains, preserve the child." The 
ergot was the proper remedy ; as I believe it would supersede the use 
of instruments. I have italicized parts of Dr. D's. directions, with a 
view to point out the important omissions in those of Mr. Burns. 

1468. I would, without hesitation, have recourse to turning, under 
the circumstances just stated, and the ergot had failed, (1449;) or, 
if the forceps were not at hand, or within timely reach, rather than 
supinely see the child perish; unless, let it be observed, the waters 
had been so long drained off, and the uterus so firmly contracted as 
to hold out no prospect of success, or unless the head of the cfiild 
had escaped from the mouth of the uterus: I would disregard the 
head being at the inferior strait, provided it was still enclosed in the 
uterus : the waters not too long expended : and the head easily 
moveable in the pelvis. For I agree perfectly with Dr. Denman, it 
is sometimes best to go beyond the common rules of art, if we can 
save the child by doing so. 

1469. 5th. " When the presentation is preternatural, (that is, 
agreeably to Mr. Burns, when any other part than the head pre- 
sents,) these directions are to be attended to, and the practice is 
also to be regarded by the general rules applicable to such labours." 

1470. I have stated that the woman may be delivered without 
assistance, when either the head, breech, feet, or knees present; 
but confessed, however, that the head is certainly the most favour- 
able of these presentations. I have laid down rules for the manage- 



456 ON PRESENTATIONS, &C. 

ment of each of these varieties of labour, when they are, and when 
they are not, complicated by accidents, which must constantly be 
kept in view in the management of the case in which the cord has 
prolapsed, of which we are now speaking. Mr. Burns' last direc- 
tion contains just principles, and are worthy of attention ; they 
would have been still more useful, had he followed the plan of Dr. 
Denman, by specifying the particular treatment of preternatural 
labours, accompanied by a falling of the cord. 

1471. Dr. Denman says, " When there is a descent of the funis, 
with a preternatural presentation of the child, our conduct, must 
have regard to both these circumstances. 

'1472. " Should the breech present, the case will very much re- 
semble the presentation of the head; that is, the same methods for 
replacing the cord may be tried, and with rather a better chance of 
success. If these fail, instead of considering the labour as one of 
those which is to be resigned to the natural efforts,, it may be 
expedient at a proper time to bring down one or both of the inferior 
extremities, taking care that the funis be not entangled between the 
legs of the infant. 

1473. "Should the arm present, and such presentation be compli- 
cated with a descent of the funis, very little difference of conduct 
will be required; because, in the first place, we should determine to 
turn the child, and deliver by the feet, and the additional circum- 
stance of the descended funis can require nothing more to be done. 
Yet when the feet of the child are brought down, if the pulsation of 
the funis be lively or perceptible, it may sometimes admit of a 
debate whether it will be most proper to hasten the delivery, 
especially if the os uteri be not sufficiently open, or to leave it to be 
expelled by the returning pains. In either case it will, however, be 
right to attempt to return the funis within the uterus, and if it be in 
our power, out of the way of compression." 

1474. Though the above directions are perfectly clear, and well 
understood by the experienced practitioner, they are far from being 
sufficiently explicit to the student or the young practitioner. I 
would cite, as an instance of the deficiency of precision, the expres- 
sion, u it may be expedient at a proper time to bring down one or 
both of the inferior extremities." How would the unskilled know 
when the proper time for bringing down the feet had arrived? For 
the measure must be either useful or worthless : if useful, the unin- 
formed should be instructed what constituted the proper time, that 
advantage might be taken of it: if worthless, it should not have been 
named, as it might create embarrassment. We will endeavour to 
supply the deficiency of Dr. Denman by stating that the proper time 
for bringing down the feet when the breech presents, especially when 
complicated by the falling of the funis is, 

1st. When the uterus is well dilated, and the external parts well 
disposed to relax. 

2d. When the breech does not descend with sufficient rapidity, to 
give promise that the cord should not be long compressed. 



RUPTURE OF THE UTERUS. 457 

3d. When the breech is ill-situated as regards the pelvis, (860,) or 
when it does not readily engage in the superior strait. 

4th. When the cord is likely to suffer, or is actually suffering com- 
pression, and the child's life threatened, if not speedily relieved. 

5th. When there is a deficiency or the absence of adequate pains. 

1475. As another instance, we may produce the caution, " taking 
care, (in bringing down the extremities,) that the funis be not en- 
tangled between the legs of the infant." In suggesting this caution, 
Dr. D. shows himself thoroughly well acquainted with the contingen- 
cies of the operation of bringing down the feet ; a contingency that 
has too often defeated the object of interfering with the labour, but 
he neglected to inform the inexperienced practitioner how this is to be 
avoided. He should have informed his readers, that the cord would 
most probably descend on one of the sides of the pelvis ; and (almost) 
consequently, would be found either on the fore or hind part of the 
child. If on the fore part, the cord should be carefully carried up 
with the hand that is in search of the feet, and when these are found, 
the cord should, if possible, be made to pass over them, and made to 
lie above the legs, and upon the belly of the child, which will cer- 
tainly prevent its getting between these extremities. 

1476. If it descend on the back part of the child, it should be re- 
turned, above the brim of the pelvis, by- the hand not to be employed 
for bringing down the feet : this will entirely remove it from the risk 
of its becoming entangled between the legs. (See rules for bringing 
down the feet in the breech presentations, 892, et seq.) 

1477. If it descend on the anterior, or posterior portion of the 
pelvis, the cord should be removed to one of the sides of the pelvis ; 
and, when practicable, to that side to which the back answers. 

1478. If it should be found to descend between the legs of the 
child, the feet must not be brought down, until the cord has been 
slipped over one of the legs. 

1479. If it be judged proper to use the forceps, their employment 
must be subject to the rules which govern their application ; always, 
however, being certain, that the cord is not interposed between the 
blade of the instrument, and the head of the child. 



CHAPTER XXXIX. 



OF RUPTURE OF THE UTERUS. 



1480. During labour the uterus every now and then is ruptured ; 
and, perhaps, even oftener than at present we dare assert — sometimes 



458 RUPTURE OF THE UTERUS. 

this accident is concealed, from ignorance ; and, at others from design : 
hence, many cases must occur of which the profession remains unin- 
formed. Nothing can justify the concealment of this event, though we 
can promise ourselves but little by the avowal ; but it is a duty we 
owe the connexions of the unfortunate woman, as well as the pro- 
fession itself. Concealment often arises from a previously adopted 
theory upon this subject; and the supposed risk of professional repu- 
tation ; than which nothing can be more disingenuous, or hypothetical. 
I would, in one word, recommend, in all such cases, its most speedy 
avowal, to those immediately concerned in the event ; and must 
declare, I should consider the contrary conduct as highly derogatory 
to the honourable feelings which every medical practitioner should 
possess; as well as doing serious injury to the advancement of obste- 
trical knowledge. 

1481. In treating this subject, I shall, first, consider whether it be 
proper to attempt any thing for the woman's relief, as there is much 
authority against it ; and because it is constantly made the plea for 
the concealment of this accident ; secondly, I shall take into view the 
variously reputed causes of it, with their mode of action ; thirdly, 
detail the symptoms and consequences of the rupture ; and fourthly, 
indicate the mode of proceeding, under the various circumstances with 
which the accident may be complicated. 

1482. Dr. Hunter considered any attempt to relieve a woman who 
had suffered a rupture of the uterus, as cruel — therefore it was not to 
be attempted. This opinion was afterwards more strongly enforced 
by the late Dr. Denman, who declared, that " when the uterus is 
ruptured at the time of labour, both reason and experience show, that 
the patient has a better chance of recovering by resigning the case to 
the natural efforts of the constitution, than by any operation, or inter- 
position of art." 

1483. I consider the assertion of Dr. Denman to be in opposition 
both to " reason and experience :" to reason, because it would be a 
natural suggestion, that that woman's chance would be best, from 
whom many of the causes were removed, that would hinder recovery, 
by the delivery of the child, &c. ; and to experience, because we have 
the most unequivocal proofs of recovery, upon record where "the in- 
terposition of art" was resorted to. 

1484. Thus, Heister,* Douglass,! Hamilton, f Ross,§ Kite,[| Ma- 
dame La Chapelle,^! relate cases of entire recovery after the delivery 
of the child, through the natural passages ; while Hamilton,** Thi- 
baultjff Lambron,f{ &c, give others of equal success, where gastrec- 
tomy had been performed. In all of these, however, the success was 

* Instit. de Chir. torn. II. p. 137. t Essay on Rupture of the Uterus, p. 7. 

X Outlines, p. 344. MS. Lectures. § Annals of Med. Vol. III. p. 377. 

|| M<m. Med. Soc. Vol. IV. p. 253. IT Annuaire Med. Chir. torn. 1. p. 542. 

** MS. Lectures. ft Journ de Med. for 1768. 
tt Baudelocque, Vol. III. p. 430. 



RUPTURE OF THE UTERUS. 459 

confined to the mother ; the child was uniformly dead ; but I have 
strong reason to believe, that this was very much owing to the delay 
which took place before the operation was performed. Tndeed, 
Burton* renders this almost certain, by the relation of a case which fell 
under his notice: in this, the child was delivered alive, though the 
mother died ; while Mr. Haden relates an instance of the preservation 
of both mother and child. f 

14S5. Thus, we can most successfully destroy Dr. Denman's cele- 
brated aphorism on the subject of the rupture of the uterus, by pro- 
ducing cases, in which the " interposition of art" was followed by 
success. This, I think, should put the matter to rest; especially as 
there is no instance extant, at least with which I am acquainted, 
where the woman recovered at the full period of utero-gestation, 
when the child was permitted to remain undelivered. 

1486. There are a number of instances upon record, purporting to 
be recoveries, after the rupture of the uterus, where the foetus was 
permitted to remain in the abdomen — but they are liable to strong 
suspicion, and are far from standing the test of rigorous examination : 
they appear to be cases of extra-uterine conceptions, chiefly ; or of 
but the partial rupture of the uterus. By partial rupture, / mean, 
wliere the muscular substance of this organ has suffered laceration, but 
where tlie wound does not pass through its peritoneal coat. Of this 
kind, are the cases related by a writer in the Jour, de Med. for 1780, 
also those of Drs. Bell and Sims.J Dissection proved, in several of 
these cases, that the peritoneum suffered only from distention. Mr. 
Dunn relates a case of rupture of the uterus, where the child was de- 
livered per vias naturales. The patient was several times alarmingly 
ill after her delivery, but recovered eventually ; and he delivered her 
of three children after, between the summer of 1830, and Feb. 1833. — 
(Edin. Med. and Sur. Jour, for July, 1833, p. 72.) — This case is one 
of the most remarkable of its kind upon record, and completely justi- 
fies the attempt to deliver in ruptures of the uterus. It perfectly en- 
forces the opinion expressed by Dr. Denman's remarks upon the case 
of his very worthy, able, and experienced friend, Dr. Douglass, and 
completely settles the propriety of the immediate interference of the 
accoucheur, in all cases where the chance of instant delivery can be 
accomplished. And from all that I can learn from others, or my own 
experience, I cannot see any reason for withholding aid from the 
afflicted woman, who may have suffered this calamity — except, in- 

rt. of Mid. § 43, p. 110. 

+ Dr. Divis relates a case of the rupture of the anterior portion of the uterus from 
which the patient recovered in about six weeks. In this case, the child was delivered 
by the craniotomy forceps, after having 1 its head opened by Smellie's scissors. The 
neck of the bladder was so severely wounded, from its connexion with the portion of 
the uterus injured, as to prevent her retaining' her urine ever after. This case, though 
unfortunate as regards the last named injury, is nevertheless a case in point, to show 
that the woman may recover after the uterus has been lacerated. 

\ See Essays on Subjects connected with Midwifery, where this subject is treated 
at large, (p. 201,) by W. P. Dewees, M. D. 



460 RUPTURE OF THE UTERUS. 

deed, in that forlorn condition of the patient, where she would die 
before aid could be given. But what can we promise ourselves, by 
not attempting delivery ? for I must again repeat, that there is no 
instance of recovery, at full time, from a rupture of the uterus, where 
the foetus was permitted to remain in the abdomen of the mother — 
nor should the opinions of Dr. Hunter, Dr. Denman, and Mr. Burns, 
be considered sufficient authority, in such cases, to screen from repre- 
hension any one who may have neglected an opportunity to discharge 
what I consider his bounden duty, by delivering his patient instantly, 
if practicable, when she has suffered a laceration of the uterus. 

1487. Indeed, the objections of Dr. Denman are not entitled to the 
smallest weight upon this point ; since he is entirely at variance with 
himself. In his " Introduction to Midwifery,"* he appears to have 
entertained rational and liberal views upon this subject ; he there 
tells us, that, " besides some few others, (cases of rupture,) of which 
I have been informed, or which are recorded, a case has occurred to 
my very worthy , able, and experienced friend. Dr. Andrew Douglass, 
in which the uterus was ruptured ; he turned the child, the patient 
recovered, and had afterwards children." And Dr. Denman ob- 
serves upon this case, "If no other case had ever occurred, I appre- 
hend this would be sufficient authority to render it, in future, the in- 
dispensable duty of every practitioner to act in a similar manner ; and 
bad as the chance is of the patient, to be strenuous in using all the 
means which art dictates to extricate her, if possible, from danger, or 
to preserve the child." 

1488. Dr. Denman has by no means satisfied me, or, perhaps, any 
one, why his sentiments underwent a change upon this subject ; and 
the more especially, as it is a change to be considered unfriendly to 
the cause of science, and to the interests of humanity — it seems he 
has drawn a conclusion upon this point, that satisfied himself; though 
totally gratuitous, in the estimation of every body else ; namely, that 
" there are more instances upon record of recoveries of women who 
have not been delivered, than those who have been delivered after 
rupture of the uterus." 

1489. Were this position of Dr. Denman really founded in fact, 
it would deserve the most serious consideration ; but as strong*doubt, 
must be entertained upon this point, it has not changed my opinion : 
first, because the subjects of comparison are not equal ; as very many 
more women have been suffered to remain undelivered after rupture, 
than have been delivered ; consequently, a conclusion cannot legiti- 
mately be drawn ; as the proportions they bear to each other cannot 
be known ; secondly, because, I deny that there is a well attested 
instance of the woman's recovery, when she was permitted to remain 
undelivered. 

1490. From all I can collect from the histories of cases of ruptured 
uteri, it would appear that life is prolonged and suffering abated by 

* Vol. II. p. 117. 



RUPTURE OF THE UTERUS. 461 

delivery ;* it, therefore, involves a great moral question ; and if the 
facts be as I have stated, and as I most seriously believe (hem to be, 
it must resolve itself into inculcating it as an obligation, that we 
deliver whenever practicable, after the uterus has suffered lacera- 
tion. 

1491. Upon a comparison of an equal number of cases delivered 
after rupture, with those not delivered, it was found that the women, 
who were delivered, lived much longer on the average, than those 
who were not delivered ; now, if death can be suspended by our ef- 
forts, even for a short time, it will follow, it becomes a duty to make 
them ; and, if we add to this, what we have very confidently asserted, 
that there is no instance of recovery where delivery has not been per- 
formed, this fir>t part of my inquiry must be terminated by declaring, 
it is almost always proper to interpose art, in cases of ruptured uteri. 

1492. Very many causes are assigned for the - rupture of the 
uterus ; some of which appear totally incompetent to this end ; while 
others, of powerful agency, are but slightly glanced at. La Motte 
believed that the struggles of the child were capable of this accident ; 
hence, by him, they are enumerated as a cause. In this he has been 
followed by Levret and Crantz — indeed, I may say some late writers. 
But the child is almost always passive when the accident happens ;f 
and I may add, in proof of this, that the uterus has given way, after 
the death of the child. 

1493. Dr. Denmani says, " the uterus may, independently of dis- 
ease, be mechanically worn through in long and severe labours, by 
pressure and attrition between the head of the child, and the pro- 
jecting bones of a distorted pelvis, especially if they be drawn into 
points or a sharp edge." To this doctrine I cannot subscribe ; first, 
because, before the membranes are ruptured, the head cannot rest 
with sufficient firmness against any given point to produce the neces- 
sary degree of "attrition ;" secondly, that after the evacuation of the 
waters, the body of the child is so firmly embraced by the contract- 
ing uterus, that " attrition " cannot take place ; thirdly, there could 
not be sufficient friction generated between the smooth surfaces of the 
child's head and the uterus to produce it ; fourthly, in such cases, 
the child's head should also exhibit marks of this " attrition," yet of 
this no mention is ever made. 

1494. Salmathus, agreeably to Mr. Burns, considers a " thinness " 
of the uterus as a predisposing cause of rupture — but we have no 
evidence in any case whatever of this "thinness" existing as an 
original conformation of the uterus before the rupture takes place; if 
it be found thin, (post mortem,) it may be occasioned from mere ex- 
haustion of blood, and not by an original condition of this organ. 

* See Essays on various Subjects connected with Midwifery, by the author, p. 
227. 

t Baudelocquc. $ Introduction, p. 105. 

40 



462 RUPTURE OF THE UTERUS. 

Mental agitation and frights are also said to occasion rupture of the 
uterus ; but strong doubts should be entertained of such causes. 

1495. I shall, therefore, pass without notice many causes reputed 
as capable of causing this accident ; and consider only such, of whose 
agency no reasonable doubts can be entertained. I shall divide these, 
first, into those which act directly upon the uterus ; and, secondly, 
into those which have an indirect influence. 

1496. The first may be considered mechanical violences, and may 
be both external and internal. The external may be blows, kicks, 
or violent pressure ; the internal may be, ill-conducted attempts to 
turn the child ; the attempts to return a prolapsed limb ; the mal- 
adroit use of instruments; or the unequal surface of the child itself. 

1497. The second, or indirect, are such causes as may have a 
tendency to injure the continuity of the uterus, by mechanically im- 
peding the passage of the child : as a contracted pelvis ; an unusual 
sharpness in the linea ilio-pectinea ; exostoses, tumours, scirrhi, and 
ulcers. 

1498. The action of these two sets of causes are different ; the 
first act directly, by exerting a force beyond the resisting power of the 
uterus : the second, by diminishing the strength of a particular por- 
tion of this viscus, so that its own contraction may be sufficient to 
overcome the resistance which this weakened part offers. 

1499. The mode in which the first set of causes acts, is sufficiently 
obvious without farther explanation. The second is not so clear, yet 
of most easy explanation. The head of the child, covered by the 
uterus on all sides, cannot, in a contracted pelvis, readily engage 
in the opening of the superior strait ; it must, therefore, rest for a long 
time stationary, or nearly so, at its margin — if this be sharp, or pro- 
jecting, the uterus will suffer in proportion to the weight of the child, 
the force of the contractions of the uterus, and the period it may suf- 
fer this compression — inflammation ensues : and if the cause be not 
soon removed gangrene will follow: when the uterus is thus 
weakened, it will be easily understood how a small force may 
rupture it. 

1500. The second set of causes acts by preventing a regular 
development of the different portions of the uterus during pregnancy; 
consequently, one portion or other is put unduly upon the stretch, 
and of course weakened; and by its remaining passive during labour, 
by being diseased, it cannot resist the efforts of the healthy portions. 
When the action of the uterus itself is the cause of the rupture, it 
always takes place at the moment of the greatest severity of pain. 
Boer and other German pathologists, have rendered it probable, that 
that peculiar condition of the uterus called " Softening," may be a 
cause of the rupture of this organ ; for though it is never perhaps 
absolutely until after death, yet it is rendered probable that it may 
exist during pregnancy, though perhaps in an inferior degree to what 
is observed in post mortem examinations, yet to a sufficient extent to 



RUPTURE OF THE UTERUS. 463 

cause rupture during labour ; and this may also, agreeably to the 
same authority, be the cause of the death of the foetus in the last 
period of utero-gestation. 

1501. Rupture may happen to any portion of the uterus; or in 
any direction : or at its connexion with the vagina— it may be more 
or less extensive ; and the child with its appurtenances may pass 
entirely, or partially, into the abdominal cavity. 

150*2. When this accident happens, it almost always declares 
itself by such symptoms as cannot well be mistaken. I shall now 
consider those symptoms, under the third division of our subject. 

1503. Crantz, Levret, and others, have supposed that the rupture 
of the uterus might be foretold by premonitory symptoms ; but I am 
very certain that few things can be more equivocal than the symptoms 
pointed out by Crantz ; namely, that, " when a woman is threatened 
with a rupture of the uterus in a laborious labour, the belly is very 
prominent and tight; the vagina lengthened, and the orifice of the 
uterus very high ; the pains are strong, leave little interval, and do 
not advance delivery. " I have seen all these symptoms in their most 
exalted form, without the labour terminating by rupture ; and in Mrs. 
M's case, which fell under my notice, and of which I have given a 
detail,* " strong pain with little interval" were not among its pre- 
cursors ; though a very extensive laceration of the uterus took place. 
M. Levret has added to these symptoms, but without increasing their 
certainty, " that the pain the woman suffers, is always seated towards 
the middle of the epigastric region ; that a last effort, or violent leap, 
succeeds to the repeated strugglings of the child, which announces 
its death and the rupture of the uterus." 

1504. Did the signs just detailed portend a rupture of the uterus, 
every laborious labour would be threatened with one — every symp- 
tom enumerated above, is almost the necessary effect of the tonic 
action of the uterus, after the evacuation of the waters ; yet fortunately 
for suffering woman, this accident is of comparatively rare occur- 
rence. 

1505. The signs added by Levret are frequently witnessed, with- 
out a rupture supervening: and it has occurred, where these marks 
were absent — it is also well known, that the uterus has given way 
after the death of the child ; (Annals of Med. Vol. iii. p. 293, 303,) 
I, therefore, perfectly agree with Baudelocque, that " the rupture of 
the uterus has often taken place without being preceded by any of 
them, and has not happened in other cases where their union declared 
it inevitable." The conclusion from this must be, that it would be 
extremely hazardous to act upon the presumption, that a rupture of 
the uterus was about to take place, because of the presence of several 
of the symptoms just mentioned; who could justify the employment 
of the forceps, or crotchet, or perform the difficult and oftentimes 

* See Essays on various Subjects connected with Midwifery, by the Author, p. 238. 



464 RUPTURE OF THE UTERUS. 

dangerous operation of turning, upon a mere surmise that this acci- 
dent might take place ? 

1506. I have said enough, I trust, upon the uncertainty of any 
sign or signs that would announce a rupture to be at hand ; I shall, 
therefore, pass to the enumeration of the symptoms which declare it, 
after it has taken place. 

1507. The woman feels, for the most part, an acute pain at the 
place at which the rent happened — she generally cries out, and 
declares that something terrible has happened within her — the rup- 
ture is said sometimes to be accompanied by a noise which has been 
distinguished by the by-standers — a discharge of blood of greater or 
less extent takes place from the vagina — her face becomes cold and 
pale — her respiration hurried — she is sick at stomach, and most fre- 
quently vomits — the matter discharged is sometimes the common 
contents of the stomach, at other times it consists of a very dark, 
even black-coloured substance resembling coffee grounds — the pulse 
is extremely frequent, small, fluttering, or extinct — she complains of 
a mist before her eyes, loss of sight, and extreme faintness — a cold 
clammy sweat bedews the surface of the whole body, and if not 
speedily relieved, convulsions and death follow. 

1508. These symptoms are, however, modified by several circum- 
stances: 1st, whether it be the uterus itself, or its connexion with the 
vagina, that may be ruptured ; 2dly, whether the child has escaped 
in part or entirely into the cavity of the abdomen ; 3dly, whether the 
lesion has passed through the substance of the uterus alone, or has 
penetrated the peritonaeum. 

1509. 1. When the rupture has taken place either in the body or 
neck of the uterus, the pains either cease or slacken so much as not 
to propel the child, if it be still retained within the uterus. 

1510. 2. When the child escapes entirely into the cavity of the 
abdomen, through the torn uterus, the most distressing and alarming 
symptoms quickly follow — if but partially protruded, pain may effect 
the delivery of the child, or it may be extracted by art. 

1511. 3. Should the wound stop at the peritoneal covering of the 
uterus, and not penetrate the abdomen, there is reason to believe that 
the symptoms will not only be milder, but the chance of recovery in- 
creased. 

1512. However strongly and decidedly marked the symptoms 
which accompany rupture may be, they are not exclusively to be re- 
lied on — but when they have excited suspicion, by their severity and 
character, we should lose no time, before we ascertain it ; this is to 
be done by a careful examination of the abdomen and the uterus ; the 
first by the application of the hand externally, and the other by the 
finger or hand per vaginam. Should the accident occur before the 
rupture of the membranes, the tumour which they formed will shrink 
away ; for, if the rent be through to the abdomen, it is more than pro- 
bable that the membranes will give way, and the waters bi i discharged 
within it ; but should the lesion stop at the peritoneum, they may re- 



RUPTUKE OF THE UTERUS. 465 

main entire for some time, though they may not again form a bag 
within the circle of the os uteri. 

1513. When the abdomen is examined externally by the hands, 
the foetus, if the rupture be complete, may readily be distinguished 
through its parietes ; if the foetus cannot be thus detected, it is pre- 
sumable that it has not escaped entirely from the uterus — but we are 
to ascertain this by a careful and more extensive examination. 

1514. If the accident take place after the discharge of the waters, 
the presenting part will either recede beyond the reach of the finger, 
or can be easily forced back by its pressure, (provided the head or 
presenting part has not already engaged in the pelvis,) — if the former 
obtain, the hand should be introduced, and the nature of the case 
clearly ascertained — should the os uteri be well dilated or easily dila- 
table, the hand should be passed into the cavity of the uterus, so that 
the extent of injury be well understood. But should the os uteri be 
firmly contracted, so as to refuse admission to the hand, without the 
application of much force, the point should be given up ; for nothing 
can justify a violent entry into the cavity of the uterus. 

1515. When the laceration takes place at the neck of the uterus, or 
at its union with the vagina, the child, with its appurtenances, almost 
always pass into the cavity of the abdomen : in either of these cases, 
the presenting part will immediately remove itself from the superior 
strait: when this happens, we should, as quickly as possible, ascertain 
whether the accident has taken place, of which this circumstance 
would instantly give the suspicion. In cases like these, the examina- 
tions to this effect are more easily conducted, than when the body or 
fundus is the subject of the laceration; as the parts involved in the 
mischief, cannot contract like the uterus itself — the uterus, under such 
circumstances, will be found, for the most part, firmly contracted 
either on the posterior or anterior portion of the pelvis, as it may hap- 
pen to be the posterior or anterior portion of the vaginal circle, that 
may have sustained the injury — the intestines will frequently prolapse 
through the wound, which removes at once all doubt as to the nature 
of the accident — it is almost needless to suggest the propriety of a 
cautious and gentle examination, after the hand has entered the ab- 
domen. 

1516. When the nature of the accident is ascertained, it behooves 
us immediately to attempt the relief of the unfortunate woman ; and 
the means for this purpose are — first, to attempt delivery per vias na- 
turales ; and secondly, to perform the operation of gastrotomy. 

1517. We may perform the first, whenever the neck, or its union 
with the vagina is the seat of laceration, provided the pelvis is of a 
good conformation, and the child has escaped into the cavity of the 
abdomen — the feet of the child should be sought for, and the delivery 
accomplished as in a case of turning — but should the pelvis be so 
contracted as not to permit the child's head to pass, this mode of de- 
livery must be changed for the second. Should but a portion only of 
the child have escaped through the rent, and the head be engaged in 

40* 



466 RUPTURE OF THE UTERUS. 

the pelvis, the forceps should be used, or if we are certain of the 
child's death, the crotchet may be employed. 

1518. When either the body or fundus, or both, have suffered, and 
the child has escaped into the abdomen, the delivery per vias naturales 
may be either difficult or impossible, even in a well-formed pelvis ; 
for the uterus will most probably contract itself so much as to render 
the re-passage of the child impracticable ; the only chance, in this 
€ase, is the immediate performance of gastrotomy: should a con- 
tracted pelvis complicate this case, the latter operation is the only 
alternative. But should the uterus remain flaccid, and its mouth yield- 
ing, and the pelvis well-formed, we may succeed, though with diffi- 
culty, through the natural passages — but if this flaccid state of the 
uterus be attended by a deformed pelvis, the abdominal section is the 
resource. 

1519. Should the vagina alone suffer, and the child pass into the 
abdomen, we should deliver by the natural passages, provided the 
condition of the pelvis will permit: if it should not, gastrotomy must 
be had recourse to.* 

1520. The operation of gastrotomy, I believe, is one which has 
never been performed in this country on the living subject, for rupture 
of the uterus ; but there is no reason why it should not, when circum- 
stances are sufficiently imperious — we have the experience of the 
European surgeons in its favour; and, however appalling it may 
appear, when viewed merely as an operation, it nevertheless would 
seem to add but very little additional suffering to the unhappy 
woman, f 

1521. But to derive advantage from this operation, "it should be 
performed as quickly after the accident as possible, while the patient 
still retains strength ; and the incision should always be made on the 
side of the abdomen which corresponds with the rupture of the uterus,":): 
if practicable ; or I may add, if that side can be detected. Should 
either the anterior or posterior portion of the uterus have yielded, the 
child will most probably be in the middle of the abdomen,) provided 
the woman had not changed her position after the accident,) in which 
case the incision would perhaps be best made in the linea alba, as if 
the Cesarean section were about to performed. 

1522. As every ease must necessarily be interesting, as well as 
instructive, in which bold and judicious operations have saved life, I 
will relate some instances of success, following the operation of gas- 
trotomy.. 

* The reader, if he wish to see this subject more amply treated, may find it in 
u Essays on various Subjects connected with Midwifery," by the author, p. 201. 
t Thibault des Bois, Jour, de Med. for 1768. 
X Path. Chirur. torn.. II. p. 239, par. M. Lassus. 



RUPTURE OF THE UTERUS. 467 



Gastrotomy. 



1523. Dr. L. Frank relates the following interesting, though rather 
too generally described cases, in which gastrotomy was successfully 
performed. 

1524. Angela Grossi, of Parma, aged forty-four, had borne five 
children, and had reached the ninth month of her sixth pregnancy, 
without the occurrence of any accident. On the morning of the 9th 
of August, 1817, labour commenced ; and whilst standing up she was 
seized with a faintness, accompanied by vomiting. She was there- 
fore placed on her bed, by the assistance of her husband and midwife. 
At that moment she stated that she experienced a feeling of laceration 
in the abdomen, and also a sensation of there being two children. A 
surgeon who was called in, asserted that the effort of vomiting had 
carried the child upwards ; adding, that another might propel it down- 
wards ; and advised the patient to remain quiet. 

1525. " The midwife, however, remarking that the abdomen 
swelled, that the vomiting did not cease, and that the breathing be- 
came irregular, called in Dr. G. Rossi. On examination, he detected 
a rupture of the uterus ; and on consultation with his father, and other 
medical men, it was unanimously resolved, to have recourse to gas- 
trotomy. 

1526. " Two hours after the occurrence of the accident, the opera- 
tion was performed by Professor Cecconi, in the left hypogastric 
region, precisely at the point where the feet of the child were felt. 
When the incision was made, the child presented with the feet, and 
was extracted alive, together with the secundines. No bad symptoms 
are alluded to, and it is stated that the patient was perfectly recovered 
forty days after the operation. Three years after she had a seven 
month's child, which lived a fortnight. After her recover}*, a ventral 
hernia presented itself in the situation of the cicatrix, which, though 
irremediable, was not productive of much inconvenience. "* 

1527. In Germany, the operation of gastrotomy has been performed 
with success, by Mr. Bulk, upon a woman of good constitution, and 
of thirty-six years of age. The patient, during her pregnancy, suffered 
from a severe pain in the left and inferior side of the abdomen : her 
menses were not suppressed ; and every six or eight days a clot of 
blood and mucus came away from the vagina. Her general health 
was good. 

1528. About the middle of the eighth month, while she was wash- 
ing some linen, she suddenly felt as if something was tearing in her 
abdomen ; at the same time, a swelling of the size of two fists, (poins,) 
formed in the right side, below the umbilicus. She fainted ; and 
during six weeks she suffered dull pains in the abdomen. At this 
time she had true labour pains for forty-eight hours, and was attended 

* Anderson's Quarterly Journal. Vol. II. No. 1, for Oct. 1825. 



468 RUPTURE OF THE UTERUS. 

by a midwife. The os uteri dilated so little as to admit but one 
finger. The tumour disappeared during these pains. The patient 
recovered, with the size of the abdomen undiminished. 

1529. In this condition she continued for two years and three 
months, menstruating regularly. She became again pregnant, and 
suffered but little inconvenience until the seventh month ; when her 
abdomen became painfully distended, and of a bluish colour ; fluctua- 
tion was induced on the least motion. At the full period, she was 
delivered of a large fetus, which she suckled for fifteen days ; the in- 
fant then dying of an aphthous affection. 

1530. The milk ceasing to be secreted, she declined rapidly with 
hectic symptoms ; the tumour reappeared below the umbilicus, of 
about the size of an egg ; it soon opened, and discharged pus from 
small orifices. The patient's constitution was rapidly yielding, and 
gastrotomy w T as immediately performed. An incision was made with 
usual precaution through the linea alba into the cavity of the abdomen, 
from two and a half inches above the umbilicus, to within nine lines 
of the pubis ; care being taken to confine the intestines. A foetus of 
full size, in which putrefaction had commenced, was found on the 
right side of the uterus. "I raised," says the operator, " the body 
with much care, and endeavoured to trace the umbilical cord. This 
was turned over the uterus to the left side, and terminated in a vas- 
cular substance in a state of suppuration, (probably the remains of the 
placenta,) which was situated below the great omentum. I pressed 
out and dried up, by means of a sponge, the pus which covered these 
parts. The uterus was an inch and a half in length, and an inch in 
breadth, of a pale rose-colour, and could easily be distended, (se laiss 
ait distendre aisement,) it was otherwise in a good condition." 

1531. The wound in the abdomen was closed by sutures. The 
patient was in great danger from inflammatory symptoms for eight 
days ; but eventually she recovered. She left her bed on the fifty- 
fifth day. 



PART IV. 



ON DELIVERIES PERFORMED RY CUTTING INSTRUMENTS, APPLIED EITHER 
TO THE CHILD OR MOTHER. 



1532. Hitherto I have been treating of labours which could be 
terminated by the natural agents of delivery ; those in which the hand 
alone could perform it ; and those in which it was necessary and 
proper to employ such instruments as were calculated to preserve both 
mother and child. I have now to consider those unfortunate instances, 
in which the labour is impracticable without either mutilating the child, 
or subjecting the woman to the Csesarean section, or the section of 
the ossa pubis, commonly called the Sigaultean operation. 

1533. There are a number of causes which may place an unfortu- 
nate woman in the predicament of having her child mutilated, or force 
her to submit to the alternatives just mentioned. These causes are, 
1st. A deformity of the pelvis; 2d. A deformity of the child, or its 
monstrosity ; 3d. Accidental deformity, as hydrocephalus, dropsy of 
the abdomen, &c. 



CHAPTER XL. 



I. DEFORMITY OF THE PELVIS. 



1534. This subject has already been treated of, (45, &c. ;) but it 
was then mentioned as a mere deviation from the healthy measurement 
of the pelvis : I shall now consider the indications this unhealthy 
structure may produce. When the deviations are but small, a child 
may be delivered alive at full time ; but the labour will be more tedious 
and painful, if the child be of the ordinary size, than if the pelvis en- 
joyed its full and proper proportions. But the variations ma\ be 



470 OF TURNING IN A DEFORMED PELVIS. 

greater, or even at times excessive — the degree, therefore, will ne- 
cessarily give rise to various modes of terminating the labour by arti- 
ficial means. 
1535. The resources of art under deformities of pelvis, are, 

a. Turning. 

b. Forceps. 

c. Cephalotomy. 

d. Caesarean operation. 

e. Premature delivery. 
f Section of the pubes. 

g. Regimen during pregnancy. 



Sect. I. — a. Of Turning in a Deformed Pelvis, as a Means of saving 

the Child's Life. 

1536. When treating of this operation (turning) expressly, I took 
occasion to observe, (736,) that it was always one of hazard to the 
child, even in a well-instructed pelvis ; a fortiori, the risk must be 
greater in a contracted one. For this operation to be successful even 
under the best management, it will require, 1st. That there shall exist a 
proper relation between the diameters of the child's head, and those of 
the pelvis ; 2d. That the waters shall not have been too long drained 
off; 3d. That the breast of the child, and cord, shall not suffer com- 
pression ; 4th. That the head shall not be too long detained in the 
pelvis ; and 5th. That the neck of the child shall not suffer too much 
extension after the body is delivered. 

1537. To obtain these advantages, requires no common combination 
of favourable circumstances ; and as these, for the most part, must ne- 
cessarily be contingent, it is no way surprising that this operation 
should so often fail of success— and to all that may be required on the 
part of the mother and child to render it even probably safe, there 
must be added skill on the part of the operator ; for, without this, very 
often the child would perish, though the case may have been the 
most proper, or of the most easy performance. 

1538. Should the deformity, however, leave less than three inches 
and a half in the antero-posterior diameter of the superior strait, we 
need scarcely look to this operation for success, as regards the child ; 
and when resorted to under such circumstances, it must only be con- 
sidered as a remedy for the safety of the mother. In this country, 
indeed even the diameter just specified, would rarely be sufficient to 
give promise of success, under the best and most skilful manage- 
ment ; for the transverse diameter of the head of the greater part of 
the children born at full time, would exceed three inches and a half: 
now, should this diameter exceed this measurement but a quarter of 
an inch, or even less, it would create a difficulty that would menace 
the life of the child. I well remember once to have sorely repented 



OF TURXIXG IN A DEFORMED PELVIS. 471 

the trial, where I judged the small diameter of the superior strait 
would certainly have been equal to three inches and a half. 

1539. It will, therefore, follow, that turning in a confined pelvis 
is, and must be, of doubtful safety, as regards the child. As one 
calculated to relieve the mother, or simply to terminate a labour, 
without taking into view its effects on the child, it might in many 
instances be successful ; or, if the practitioner has been debating with- 
in himself, the comparative merits of the crotchet or turning, the lat- 
ter will unquestionably merit the preference, since it gives a chance, 
though a forlorn one, to the child. But let it be observed, the conside- 
ration should have turned upon the employment of the forceps, and 
not upon that of the crotchet ; for this should always be considered 
as a dernier resource. 

1540. We have stated, as one of the essentials to easy and safe 
turning, is, that a proper relation of diameters should exist between 
the pelvis of the mother and the head of the child. In laying down 
this axiom we would wish to be clearly understood to mean, the ab- 
solute proportions, and not the relative. Or, in other words, the re- 
spective diameters of the pelvis, shall be of such capacity, as will 
permit the head to pass without any material obstruction when its 
corresponding diameters of the head shall be presented to them. If 
this be not the case, the force which must necessarily be employed to 
overcome the resistance created from the want of this proper relation 
of diameters will be such, as but too surely to destroy the child, and 
create at the same time, difficulties, which, perhaps, can only be 
overcome by the use of cutting instruments. 

1541. Again ; we have said, that, besides the proper correspond- 
ence of diameters, as just stated, it is almost a sine qua non that the 
waters should not have been too long drained off', to render even this 
favourable disposition available. For it is a truth, which almost 
every accoucheur must acknowledge who has attempted to turn in a 
strongly contracting uterus, that the want of success by this opera- 
tion, even in a well formed pelvis, is too often owing to its being 
undertaken when the uterus is very firmly embracing the child. If, 
then, we have to contend against the two difficulties just enumerated, it 
is more, perhaps, than ten to one, that we do not succeed in saving 
the child. 

1542. We have also enumerated as another essential to the safety 
of the child, that its breast as well as the umbilical cord, shall not 
suffer compression. But what skill or foresight can guard against 
such a contingency ; nay, almost against such a certainty ? And if 
this be beyond our control, as it too surely is, we need not wonder 
at so many instances of failure in this operation. 

1543. We must again repeat, that the head must not be too long 
detained in the pelvis if success is to attend our exertions. But who 
can declare that this shall not take place ? since the exercise of the 



472 OF THE FORCEPS IN A DEFORMED PELVIS. 

most consummate skill cannot ensure it ; and who can guard against 
the ill-devised manipulations of ignorance ? 

1544. Finally, we have declared that the neck of the child must 
not suffer too much extension. But who can ensure the life of the 
child against such a necessity,* even in the hands of the skilful? 

1545. From what we have said, the conclusion will be easily col- 
lected, that, even under the more favourable circumstances, turning 
is to the child a hazardous operation ; but that, under perverse ones, 
it is but too "often fatal to it ; and, that it must ever be looked upon 
as a doubtful alternative, rather than as a probably safe resource. 

Sect. II. — b. Of the Forceps in a Deformed Pelvis. 

1546. In my general view (761) of the forceps, I endeavoured to 
prove that their powers were pretty extensive, yet sufficiently limited. 
That their mode of action (784) was that of a double lever, with no 
mean compressing power — that this power, however, could not be 
employed (781) beyond a certain degree, with safety to the child; 
That, if more were exerted, it would be at the expense of the bones 
of the cranium, and the brain of the child ; therefore, there was a 
limit to their usefulness. In a pelvis where the opening of the supe- 
rior strait in its small diameter will give three inches, these instruments 
have been successfully employed ; of which Baudelocquef gives us 
an example which not only proves the useful powers of these instru- 
ments, but shows the little certainty with which the death of the child 
is marked, even by the combination of many of the most formidable 
signs. This case is full of instruction, and should be carefully read. 

1547. But when the small diameter of the superior strait has less 
than three inches, J these instruments cannot be employed at the full 
period of utero-gestation with any chance of success. To be useful 
even then, requires that the head of the child shall be of moderate 
size, and yielding ; well situated, and that a skilful hand should apply 
them.§ As, however, they offer a better chance, if properly con- 
ducted upon the head, than turning, they should be employed always 

* For if turning has been resor'ed to, and the child delivered all but the head, the 
delivery must proceed by mechanical force, of the operator's arms, Or, preferably, by 
the forceps : this will prevent the separation of the head from the body. 

t System, par. 1898. 

t This is ihe limit fixed upon by Baudelocque and other French writers: it must, 
therefore, be borne in mind, that the Frem h inch is one line or one-twelfth of an inch 
arger than the English inch : consequently, the three inches French will be equal to 
3 T 3 y ths of the English, or three inches and a quarter. 

§ "But, inasmuch as we have not discovered the means of applying such pressure to 
and for the benefit of the child, without, in the mean time compromising the more im- 
portant interests of the mother, it should be held as the bounden duty of our art, in the 
treatment of such cases, (cases of narrow pelvis) to refrain from all inordinate forcible 
attempts to deliver with the forceps."— Dr. Davis's Elem. Oper. Mid. p. 140. 



OF THE FORCEPS IN A DEFORMED PELVIS. 473 

in preference to this pperation, when even a force not to be called 
great, would be required to make the head pass the superior strait ; 
for the child will suffer less from a compression of the head, than 
from the severe extension of its neck ; which it must necessarily un- 
dergo, when detained in a pelvis in which the opening is less than 
four inches. 

1548. It must, however, not be concealed, that these instruments 
are not safe, under the circumstances we are now considering, but in 
the hands of a few ; and are only rendered so to them, by their supe- 
rior professional attainments, and the long habit of using them. To 
the inexperienced practitioner, they should be entirely forbidden ; 
only not because they may destroy the child, but also because the 
mother may be severely, or irreparably injured by their use. Should, 
however, the defect of size be in the lower strait, and that not exces- 
sive, the forceps will every now and then answer a valuable end, as 
the following case will prove : 

Mrs. had been in labour nearly six and thirty hours with a 

first child ; the early part of her labour had been slow, but regular in 
its progress. The midwife to whose aid I was called, informed me, 
that the waters had been discharged after the uterus was well dilated ; 
the pains had all along been good ; that the child was very low, and 
seemed every moment ready to come, yet did not advance ; for so 
soon as the pain ceased, it flew back to its old place, and had done 
so for many hours. 

The woman was in good health and spirits, notwithstanding 'the 
length and severity of her sufferings : she was free from fever ; had 
had her bowels opened, and passed urine but a short time before my 
seeing her — she was short of stature, waddled when she walked, and 
was very bow-legged. Upon examining her, I found that the lower 
strait was defective in its small diameter ; the tubers of the ischia ap- 
proached too much, and thus did injury to the arch of the pubes also. 
I waited for a pain to determine its influence— the head was w r ell 
situated, but could not descend low enough to enable the vertex to 
pass under the arch of the pubes ; it was, therefore, found rather 
mounted behind it. The head did not appear large and its bones 
were supple. 

And when a pain came on, the parietal bones would ride over each 
other, and the scalp be pushed considerably in advance. I waited to 
try the influence of two or three more pains ; but the head only ad- 
vanced during their action ; for so soon as this ceased, it raised up- 
wards, as it had done for a long time, as stated by the midwife. The 
cause of the delay was obvious— the parietal protuberances could not 
be forced by the uterus below the tubers of the ischia, that the head 
might pass through the external parts. I was of opinion that nothing 
could relieve the head from its perilous situation but the forceps ; 
accordingly, I made it known to the friends of the patient, and sub- 
sequently to the patient herself — she cheerfully acquiesced in the 
41 



474 OF THE FORCEPS IN A DEFORMED PELVIS. 

decision ; they were applied, and by merely maintaining the ground 
gained by each uterine effort, without exerting much tractive force, I 
succeeded in half an hour to deliver the poor woman of a living fe- 
male child. The head was elongated to an unusual degree ; but it 
recovered its natural shape in a few days.* 

1549. It is not intended by what has been said, to discourage the 
obstetric practitioner in the use of the forceps, in cases in which their 
application might be difficult ; on the contrary, we would earnestly 
recommend to him the careful study of their mode of action, and the 
various manners in which they are to be applied. The usefulness 
and agency of these instruments in preserving the life of the child, as 
well as that of the mother, is no longer problematical ; for they have 
been confirmed by the united testimony of the European and Ame- 
rican practitioner of midwifery, for the last fifty years. 

1550. Important, however, as the forceps are known to be by 
medical men, neither they, nor the skill which directs them, are 
sufficiently appreciated by the public at large ; indeed, the practice 
of obstetrics is very far from being justly valued ; and this must, we 
fear, for a long time remain so, as tne public cannot easily be set right 
upon its utility. This involuntary injustice to this branch of medical 
science, arises mainly from the following causes. First, from the 
process of parturition being constantly viewed as an act, in which the 
practitioner has no other concern than to silently watch the operations 
of nature. This, we acknowledge, is strictly true in a very great ma- 
jority of cases ; but in admitting this, we are not to pass over without 
observation the exceptions, or those instances which require both prompt 
and judicious interference. But these exceptions are entirely lost sight 
of; and they are lost sight of, in many instances, because they cannot, 
with propriety, be made to meet the public eye, and this for reasons 
that will readily present themselves to a thinking mind, as well as the 
aversion every ingenuous mind has to the appearance of vain boast- 
ing. Yet the skilful practitioner has it often in his power to felicitate 
himself \ that he has abridged severe suffering or preserved human 
life ; but for which he neither expects nor can he receive, any evi- 
dence of public approbation. This does not, however, arise from any 
reluctance on the part of the world to do him justice, but because the 
value and the nature of his exertions, and the indispensable applica- 
tion of his skill, must for the most part remain unknown, to every 
body but himself. 

1551. Second. The difficulties with which the accoucheur has to 
contend, are almost unknown out of the profession ; on this account 
the most important operation which can possibly be performed, 
namely, the preservation of life, by the use of the forceps, is put upon 
a par, nay, it is often placed below, some of the most trifling opera- 
tions of surgery ; for the public are not aware, that the most difficult 

* I was ever after obliged to deliver this patient with the forceps ; this happened fonr 
times ; and without the smallest accident to either mother or child. 



CEPHALOTOMY. 475 

operation on the living subject, is the scientific application of the for- 
ceps, when the head of the child has not descended so low as to 
occupy the vagina. 

1552. How much greater eclat do most of the operations of surgery 
obtain, than a delivery by the forceps! yet we do not fear, nor do we 
hazard a contradiction when we say, there is no operation in all sur- 
gery, that is not more easy of accomplishment, than the rational and 
just application of the forceps. 

1553. Third. The comparative estimate of the mother's and the 
child's lives, contributes very much to lessen the value of manual 
interference in cases of difficult labour. For when any thing unto- 
ward arises, the life of the mother alone is taken into the calculation ; 
the child may be immolated without a sigh, provided it be declared 
that either it-or the mother must be sacrificed. And if it be preserved, 
it is looked upon rather as a piece of good fortune, than as an evidence 
of any superior skill on the part of the practitioner. 

1554. But let us not be supposed to charge the public with volun- 
tary injustice on this subject ; this is far from our meaning; we only 
wish to insist, that the difficulties oftentimes to be overcome by the 
accoucheur, in order to save life, is altogether concealed from public 
view ; and of the value of which, of course, they cannot accurately 
judge. Yet we feel it is proper that some delicate and proper efforts 
should be made to elevate the character of the well instructed ac- 
coucheur above the ignorant and pretending practitioner ; and to 
have, a just value set upon the most difficult operation, in the range 
of medical science. 



Sect. III. — c. Cephalotomy. 

1555. This operation destroys the child, with the intention, it is- 
said, to save the life of the mother, by preventing her from dying 
undelivered ; or subjecting her to the Csesarean operation. Dr. 
Osborn has treated this subject under two distinct heads ; in con- 
ducting which he inquires, 1st. "Into the degree of deformity re- 
quiring the crotchet, the Csesarean operation, or the division of the 
symphysis pubis ; their comparative merit examined :" 2d. He then 
makes a " comparative estimate of the mother's life, and the life of 
the child in utero." 

1556. His first inquiry results in his giving the preference to the 
erotchet ; and from the following views. He says, " whenever the 
pelvis is so distorted in its form, and so contracted in its capacity, as 
not to permit the head of the child to pass unopened, it constitutes 
that degree of laborious parturition, for which the comparison of the 
merits of the crotchet, with that of the Cesarean operation, &c, was 
instituted. Essays, p. 25.* 

* It would seem that theory, or conjecture, has had much to do in fixing the natur* 
and value of ihe child's life while iu utero, and that the low estimate attached to them-. 



476 CEPHALOTOMY. 

1557. That, " whenever a woman, falls in labour, the small 
diameter of whose pelvis measures only two inches and three-quarters, 
one of the following circumstances must take place." 

1558. "First, the child's head must be opened, and the contents 
discharged, that the bones may be permitted to collapse, and the 
volume being thus diminished, it may afterwards be extracted with 
the crotehet :" or, 

1559. " Secondly, for the certain preservation of the child's life, 
the mother must be doomed to inevitable destruction, by the Csesarean 
operation:" or, 

1560. " Thirdly, as a mean between the two extremes, the mother 
must submit to the section or division of the symphysis pubis ; an 
operation of less danger to the parent than the Caesarean section, but 
at the same time certainly less safe for the child ;" or, 

1561. "Lastly, If none of these means will be permitted, the 
wretched mother, abandoned by art to the excruciating and unavail- 
ing anguish of labour, will probably expire undelivered." 

1562. From this it would appear, that every woman who has less 
than three inches in the small diameter of the superior strait, must 
die, or be delivered by the crotchet, by the Caesarean operation, or 
the section of the pubes. if at full period of utero-gestation. In this 
all writers agree. But Dr. Osborn is of opinion that nothing but the 
crotchet should ever be employed under such circumstances, unless 
the opening at the superior strait has less than one inch and a half; 
for. when there is this opening in the anterior-posterior diameter of 
the superior strait, the child can be extracted by the crotchet, p. 64; 
and Whenever a child can be extracted by the crotchet, neither of 
the other operations should be thought of. 



has arisen more from terms, than from a difference of qualities. Thus, Alphonso Le 
Roy tells us that "the birth of animals is a quick passage from one mode of existence 
to that of another." And, ^'that the child, while in utero, lives after the same manner 
as a vegetable." Velpeau has adopted these sentiments, with no additional value to 
the profession. 

For we would ask, does this comparison prove other than that the child has life? 
It is not a dispute about terms, to call the life of the foetus while in utero, vegetable 
life; and that which maintains its existence after birth, animal life? Has any one 
demonstrated that there is any difference in the quality of that principle which we 
term life in these two. conditions of the animal ? Does not the difference consist simply 
in the manner in which this principle is maintained ? or, in other words, are not pre. 
cisely the same principles essential to the child both before and after delivery ? Cer- 
tainly they are. While it is in utero, does not the foetus require circulation, oxygena- 
tion, and nutiition, as much, quo ad hoc, as after it is bo-n? That these essentials to 
its existence are applied differently, and maintained differently, we agree ; but the 
nature, and importance of the means and agents are precisely the same. For the 
child would unquestionably die in utero, were either circulation, oxygenation, or nutrition 
withheld beyond a limited time; and death would follow, were either of these grand 
agents abstracted but for a short period after birth. 

In a moral point of view, the turpitude of destroying the life of the foetus by design, 
call it vegetable, or animal, as you pleise, will be the same; nor must we permit our- 
selves to undervalue it, or be seduced to destroy it wantonly, by employing terms 
which have no definite meaning ; or, if they have a definite meaning, the destruction 
of the principle called life must, in a moral light, be viewed as a crime. 



CEFHALOTOMY. 4777 

1563. He is led to this conclusion, first, from his estimate of the 
value of the child's life while in utero, when compared with that 
of the mother. He declares the former to be " incomparably small,' 7 
nay, "diminished almost to nothing, and affords the most irrefragable 
argument in favour of the delivery by the crotchet, in preference to 
either of the other methods," p. 24. And, secondly, from his having., 
delivered a woman safely by the crotchet, whose pelvis was said not 
to exceed one inch and three quarters, at the upper strait. 

1564. Dr. Osborn commences his inquiry, by stating, a "being in 
the uterine state of existence, sustains no immediate loss- by the de- 
privation of the living principle, and. can scarcely be said to incur 
any other positive injury. Before the operation, the child in utero 
cannot suffer mental anxiety, or apprehension from the threatened 
violence ; nor does it feel, I am persuaded, the smallest bodily pain, 
in the actual commission even of such violence." The question is 
not fairly stated here — it is not whether the child suffer from this 
violence or not; the question is, whether, it shall have a chance to 
live, or be destroyed ? The feelings of the child must not be taken, 
into consideration, in weighing the question, which life, that of the 
mother, or that of the child, must be sacrificed. For if we deal 
honestly upon this subject, and conclude, that the life of either the 
mother or child must be forfeited, we are forced to the admission,, 
that the child should be immolated, to preserve the mother. It then- 
becomes fairly a matter of comparison, which is the most valuable 
to society in all its relations. And I would yield the point without 
hesitation in favour of the mother's preservation ; and I would do so, 
were the child a thousand times more sensible than it is. For did 
we withhold an operation from a persuasion that the child in utero is, 
endowed with great sensibility, and that, like "the poor beetle that 
we tread upon, in corporeal suffering finds- a pang as great as when a 
giant dies," I say, did we withhold an operation essential to the 
mother's welfare, from these considerations, we should be exalting, 
the mere sensibility of the child above the usefulness and importance 
of the mother, to the husband, parents, friends, and to society. L 
must, therefore, insist that the sensibility of the child, be its degree 
what it may, must not be taken into the account, when this question 
is agitated. 

1565. But let us believe the child to be as void of sensibility as a 
cabbage, or any other vegetable, while in utero ;. what does this 
prove as regards the proper question? certainly, nothing — for ne- 
cessity, and that necessity absolute, can alone justify the operation. 
For, were we to permit our sympathies to get the better of our 
dutv, and suffer the mother to die from the exercise of feeling to- 
ward the child, we destroy her by such a proof of our sensibility; 
while on the other hand, it we wantonly or heedlessly kill the child, 
because we have persuaded ourselves it possesses nothing more: 
than vegetable life or life, without sensation, we murder it, in con- 
forming to an hypothesis. I therefore repeat, that the properties of*' 

41* 



478 



CEPHALOTOMY. 



the child, be they what they may, must never enter into the calcu- 
lation, when it is inevitably fixed that either it or the mother must 
be the victim. 

1586. The doctor next declares, "as children before birth are 
incapable of mental apprehension, so it is as undoubtedly true, they 
are not yet arrived at, or in possession of, bodily sensation, and, 
therefore, cannot suffer pain, or become objects of cruelty." I 
would inquire, how has the doctor ascertained that "children before 
birth are incapable of mental apprehension ?" for on this his re- 
markable conclusion is founded. Has he any proof whatever that 
this is really the case? 

1587. But before I proceed farther, let me show what Doctor 
Osborn means by "mental apprehension." — " Before the operation, 
(of cephalotomy,) the child in utero cannot suffer mental anxiety, 
or apprehension from threatened violence; nor does it feel, lam 
persuaded, the least bodily pain in the actual commission even of 
such violence," p. 38. Again : " It is certainly from that appre- 
hension, combined with other circumstances of misery, which usu- 
ally precede and accompany the act of dying, that death can in 
itself be considered as the greatest of human evils — and from every 
one of those, the child in utero is exempt." p. 37. 

15,68. From this it is evident, Dr. Orborn supposes that bodily 
sensation is dependent, upon " mental apprehension," or, in other 
words, that there can be no " corporeal suffering," if there were no 
" mental apprehension/' Is this agreeable to common, and daily 
observation t Has not the devoted ox power to perceive the " small- 
est bodily pain," because it cannot, or does not anticipate its fate 
from the butcher's axe on the morrow? Were we to adopt this 
hypothesis, it would make "mental apprehension " the cause of 
corporeal sensation, which would most effectually confound all our 
philosophy.. 

1569. If I should be charged with having wrested Dr. O's mean- 
ing, though I have fairly quoted his words; if it should be insisted 
that ''mental apprehension," meant perception, still the doctor is* 
chargeable with having employed a gratuitous datum — for he has 
not proved, that the brain of the foetus, especially at full time, (the- 
period at which the operation he advocates is to be performed,) is 
incapable of perception ; and until this be done, it is in vain to con- 
tend, that the child in utero cannot feel " the smallest bodily pain."* 
On the contrary, does not the child acknowledge this in many in- 
stances? Is it not frequently provoked by external causes to move 
its little limbs? Nay, does it not do this very frequently without, 
to us, an obvious cause? May these stirrings not be considered as 
the exercise of volition? Has it not a brain, and nerves emanating 
from it? Are these nerves mere cords without sensibility ? Is the 
brain a mere glandular mass without function? I can readily be- 
lieve their condition to be imperfect, but I cannot admit them to be 
without power or property. 

1,570, Does not the heart carry on the circulation, as certainly 



CEPHALOTOMY. 479 

and as perfectly, quo ad hoc, in the foetus as in the born child? 
Could this organ perform its functions without a certain condition 
of the nervous system \ If this be so, can the nerves be mere cords, 
without sensibility ? If the nerves belonging to the heart be sensible, 
may not all others be so? 

1571. In my opinion, then, Dr. O. has not made good his position; 
a position on which lie appears to place much reliance for the sup- 
port of his thesis, though in mine it has nothing to do with the 
question, as 1 have just observed, (1564, 1565,) for I must repeat 
that necessity, and strong necessity, alone can justify the operation 
under consideration — the preservation of the mother's life is the 
only motive to action, and the only object in view — if the child 
must be the sacrifice for the mother's safety, that sacrifice is im- 
perious, be the condition of the child what it may. 

1572. Dr. Osborn next informs us, " that they (children in utero) 
cannoi suffer from mental apprehension, is notorious to general ob- 
servation. Even years elapse after birth, before the mind is suscep- 
tible of fear, or apprehensive of danger." Admitted : but what 
does this truism prove, as regards the subject in question ? Nothing ; 
for I still must insist, that necessity alone is to govern us; and if 
governed by that, the only question to be debated is whether the child is 
to be absolutely sacrificed for the probable safety of the mother ? I say 
probable safety — for such only it is, as I shall attempt to prove presently. 

1573. If we are under the necessity of opening the child's head, 
our social feelings would derive some solace, could we be sure it did 
not suffer, or were we even uncertain of its suffering from the ope- 
ration ; but every thing opposes our drawing comfort from this source ; 
for however our understanding may be confounded by spacious argu- 
ment, or wily sophism, our feelings will constantly bear witness 
against the truth of the propositions, and the legitimacy of the con- 
clusions. And I believe that God intended it should be so. What 
evils would flow from this source, did we but convince ourselves, 
that foetal life was void of sensibility, sensation, or of value. 

1574. The crotchet has been but too often wantonly employed, 
even where the practitioner had not adopted Dr. Osborn's opinion on 
the subject of fcetal sensibility ; howmuch morefrequentlythen, will itbe 
employed when the wholesome restraint of the contrary opinion is re- 
moved ? I am persuaded that the exercise of true feeling toward the 
unborn child, has more than once saved it from a severe and painful 
fate ; but it must also be declared as my opinion, that it has too often 
fallen a victim to a false estimate of the mother's danger — fori have 
known it used where there was the most healthy construction of the 
pelvis, nnd where a little address in the use of the forceps, or even a 
little more patience, would have preserved the child from a premature 
death.* For, as Dr. Blundell well remarks, " to perforate the head, 

• I am happy to find my opinion on this subject strengthened by a similar remark 
by Dr. James, whose opportunities aftord him ample room to witne-s the abuse of this 
instrument iu the hands of ignorant practitioners ; in a note to Burn'.s Midwifery, p. 



480 CEPHALOTOMY. 

merely because the labour lingers, is a sort of murder; and if you 
do thus not from ignorance, but for the sake of saving time only, you 
are, I conceive, in foro conscientia, as criminal as the felon who dies 
on the gallows." — Prin. and Prac. of Obstet. pi 686. 

1575. Dr. Osborne farther informs us that u diseases which at any 
period attack the human body possessing sensation, with sufficient 
force to destroy life, are in general attended with such a degree of 
pain, as to- excite extraordinary motion, and some- struggle ; at least 
in articulo mortis. It is highly improbable that this should take place 
in the uterus, and the mother be insensible of their effect," p. 40. 
This statement at once brings Dr. Osborn's arguments to issue. He 
declares the struggle of an infant in utero would be an evidence of 
pain, and of course of its possessing- " sensation ;" and, that if this 
struggle did, take place even in articulo mortis, it is highly pro- 
bable that the mother would be sensible of it — now, what is the 
fact upon this subject ? Why, that I have been repeatedly informed 
by mothers, that they, were apprehensive their children were dead, 
because after a severe struggle, or. kind' of fluttering, which has been 
described of longer or shorter duration, they felt them no more — and 
every accoucher can bear witness to such statements from them. 

1576. Dr. Osborn farther urges, that, " when we are compelled by 
dreadful necessity, to open the child's head while we know it is 
living in. utero> that operation requires such extreme and painful vio- 
lence, that were the child' endowed with the slightest sensation, he 
must of necessity feel it; and his feelings must necessarily be ac- 
companied with such struggles and exertions, as would be emphati- 
cally expressive of pain, and must be readily perceived by the mother 
in a part so sensible and irritable as the uterus." p. 41. 

1577. This is sheer sophistry — it is making a negative condition 
prove a positive position ; or, in other words, it is making the absence 
of struggling prove- the want of sensation: when the situation of the 
child in utero is such, very often when it is necessary to perform this 
operation, as to render such evidence of its sufferings impossible. 
For this operation is recommended to be performed after the waters 
have been expended, and the uterus is firmly contracting round the 
body of the child. Now, it is well known to every accoucheur of 
any experience, that the uterus will, in many instances, so strictly 
gird the child as to preclude the possibility of " exertion," be its 
feelings what they may. 

1578. Besides, in a case which I witnessed of the operation of 
cephalotomy, the woman declared to me without inquiry, that the 
most painful part of it was the struggles of the child. Now, in this 
case the waters had been but recently discharged, and the uterus con- 
tracted but once in about twenty minutes. I mean not to lay undue 
stress upon this case ; for it is not essential to my argument. I well 
know the imagination does much upon such occasions; and that a 

35, note k, he says, he fears that " embryulcia is frequently resorted to, very unneces- 
sarily at least, to make use of the mildest terms." 



CEPHALOTOMY. 481 

convulsive action of the uterus may have been mistaken for the mo- 
tions of the child ; though it was precisely such a case as would lead 
to the belief, that the poor woman was correct, for the child was cer- 
tainly alive when the operation commenced ; the waters had been 
expended but a short time ; and the woman's observation was spon- 
taneous, and unprovoked. 

1579. Dr. Osborn, however, tells us, on the contrary, that " upon 
accurate and repeated inquiry in several such cases, he could not learn 
that the mother was sensible of any such alteration in the motion of 
the child, even at the commencement of the operation, when the' vio- 
lence otfered to it first takes place, and must be most painful." This 
statement o[ Dr. Osborn, amounts but to this negative; that in the 
cases in which he made u repeated inquiry," no struggles were per- 
ceived ; but this is very far from proving, that none upon any occa- 
sion could take place. For this might well happen in " several cases," 
yet not be true in all ; and if there have been one case in which the 
child was known to struggle in consequence of the operation, it is 
every way sufficient to destroy the arguments of Dr. Osborn ; since he 
makes struggling a proof of sensibility — and I most sincerely believe 
many such cases have occurred. There are two especial reasons w T hy 
this may not commonly happen : 1st. As stated, (1577 ;) and 2d. The 
child is sometimes dead before the operation is commenced. This 
statement of Dr. Osborn seems, however, to be confirmed by Dr. 
Blundell, who says, " Having given myself up to the more difficult 
part of the practice, I have too frequently had occasion to use this 
instrument, (the crotchet ;) and on these occasions, asking the mother 
whether she has felt the child move, I have usually received an answer 
in the negative. Whether it be that the sensibility of the brain is but 
small even in the adult, so that, from this cause the foetus does not 
feel so much pain as a priori, we should have expected, or whether 
some other cause be in operation, I am not prepared to decide; but 
the fact is well ascertained, and it seems that little struggling is pro- 
duced." Now, however specious this statement at first sight may 
appear, it, nevertheless, amounts to nothing. In the first place, it is 
not certain that the brain of the adult, even has a feeble sensibility, 
but injuries, like embryulcia, will certainly destroy life. A bullet 
passing swiftly through the brain of the adult, cannot be proved to be 
painful, nor will it cause struggling; but who doubted that the indi- 
vidual possessed feeling before it was destroyed, though this was so 
instantaneously done, that no token of it could be manifested. Se- 
condly. Dr. Blundell does not say he always received a negative an- 
swer to his question, but he did "usually." A single exception is 
sufficient for our purpose, and that is given us in the word " usually." 
Thirdly, there may have existed, in the majority of these cases, a 
physical impossibility to struggle, from the firmness with which the 
tonic contraction of the uterus embraced the child. In evidence, 
however, that Dr. Blundell was not confirmed in his own position, he 
says, " It is not true that the child in utero is destitute of sensibility, 
as some have imagined, as the accoucheur would willingly believe, 



482 CEPHALOTOMY. 

when he is about to use the perforator. I have, myself, in turning, 
felt the mouth of the foetus, and have inserted my finger, to know 
whether the little infant would suck. Now, in two instances, 1 found 
it has sucked as vigorously before birth as afterwards : thus showing 
that it felt hunger ; that, moreover, it perceived the finger, that it had 
sense enough to perform the operation of sucking/ therefore, that its 
mind was in action." — Princip. and Prac. of Obstet. p. 98. 

1580. u Having proved," continues Dr. Osborn, " that the loss 
whic$i the child sustains, by the deprivation* of the living principle is 
so extremely small as almost to vanish to nothing, and that its bodily 
sufferings in the act of deprivation are absolutely none, it becomes 
proper, next to inquire what is the value pf an unborn child to its 
parents and the community," p. 42. 

1581. " Before the birth of the child, parental affection has not 
taken place, which, for the wisest and best purposes, is one of the 
strongest, the most universal, and, perhaps, the most uncontrollable 
passions of the female breast: often changing even in the subordinate 
parts of the creation, the very nature of a timid mother, into that of 
a ferocious animal. Disappointment of expected pleasure only, not 
the loss of any object of this powerful passion, or the loss of any 
actual enjoyment, is the sacrifice the unhappy parent makes on this 
occasion," p. 43. 

1582. We are of opinion, that Dr. O. is far from having proved, 
(except to himself,) that which he so complacently states he has done, 
(1579.) And, if we had really " proved" that which we think he 
has merely taken for granted, it still would have no bearing upon the 
subject — the degree of sensibility of the child while in utero, or 
whether it possess any, is not the question, as I have before declared ; 
for neither view of this question should prove a motive of itself to the 
operation ; nor should either deter from it ; for this point must be 
settled upon other principles. 

1583. But where Dr. 0. learned that parental affection did not 
exist before birth, is difficult to say ; for I must declare, and I do this 
without fear of contradiction, that the affection of the parent is strong, 
nay, oftentimes very strong, for the child while in utero — and if any 
accident befall it, a sorrow, and sometimes of a deep kind, is for a 
long time indulged — I have known two instances of protracted, and 
deep-seated gloom, follow the birth of still-born children ; and in one, 
it was not removed until a subsequent pregnancy gave promise of a 
more fortunate result; the other gradually yielded to time, and change 
of scene." 

1584. It would be idle to say that these were not the cases of dis- 
appointed or lacerated affection, but the mere privation of a promised 
or anticipated pleasure. Besides, Dr. O. tells us, that "parental 
affection " converts, in the brute, " the timid mother into the ferocious 
animal ;" from w r hence arises this recklessness of danger in the " timid 
mother," in defence of her offspring, when she exposes herself to 
death, and often meets it fearlessly in attempting to protect it. What 
anticipation of future or "expected pleasure" exists in them? there 



CEPHALOTOMY. 483 

are not, nor cannot be, any promised joys here ; they look not for- 
ward for such reward ; yet they unceasingly display affection and 
courage ; that might put to shame some, who should derive delight 
from offspring. Dr. 0. could not have been a father. 

15S5. Dr. 0. pursues this subject by observing, " Had parental 
affection commenced at the time of conception, or when the embryo 
is first formed ; and had it continued increasing during gestation, as 
the fcetus advanced in growth, by the time of birth the passion would 
have been mature, and its influence most powerful, and the mother's 
suffering would have been greatly aggravated by the loss of a beloved 
child." And is this not precisely what happens in a large proportion 
of cases ? Who has not witnessed the joy of a mother at the first 
evidence she has that her child lives within her? Who has not wit- 
nessed the growing affection of the parent as gestation advances? and 
who has not observed the sorrow, when all this maternal solicitude 
has proved unavailing? What motive governs the mother, when she 
submits to the Cesarean operation, or yields to the section of the 
pubes. Love, unbounded love for her unhappy offspring! And who 
that has witnessed the dreadful operation of the crotchet, cannot bear 
testimony to the agony of the mother for the loss of her unborn child ; 
If these things were denied by Dr. 0. I must repeat, he is no father. 

1586. Dr. O. goes farther ; he declares, " such a passion, (maternal 
affection,) could not be directed to any useful purpose, during the 
existence of the child in the uterus; nature, who never performs works 
of supererogation either in the physical or moral world, has not yet 
kindled it in the mother's breast ; it begins only with birth : and pa- 
rents in general may, I think, be literally said to suffer nothing, by 
the loss of an unborn child." 

7. To this I will briefly state, that maternal affection is con- 
stantly necessary from the moment conception is believed to have 
taken place, until the final expulsion of the child from the uterus. 
Were a woman not influenced by strong affection to the protection of 
her child while in utero, she would have no reward for the many, and 
oftentimes severe sufferings, and privations, during that period ; and 
were not this love for the child paramount to every other feeling, as a 
general rule, there would be no motive for its preservation — careless- 
ness or design, might constantly circumvent the great object of crea- 
tion. And, with respect to his conclusion, I appeal to the whole 
world for its refutation. 

1583. Again, the Dr. says, " to society, likewise, the loss of any 
individual child must be exceedingly small, when it is known by daily 
-ervation, what great numbers of children are still-born, or die 
without such violence before birth ; when it is likewise known, how 
very precarious is the chance of a child's living two years; but how 
most of all precarious, is its arrival at that period of life, when it can 
be of any service to its fellow creatures, or even participate itself in 
the enjoyments of the world." (p. 45.) 

1589. To me it is truly a matter of surprise, that the various con- 



484 CEPHALOTOMY. 

tingencies which may prevent a child from being born alive, from its 
continuing two years upon earth after birth, or from arriving at man- 
hood, should be employed as an argument against the value of its life. 
It appears to me, that it should have a diametrically opposite bearing; 
for, were the birth of a still-born child a rare occurrence ; were it 
almost certain that children should arrive at the age of two years ; 
their arrival at puberty, or beyond it, nearly sure; the occasional loss 
of a child by embryulcia, or any other violence, would then be but 
little lelt ; but when such violences are to add victims to the already 
too long list of human deaths, they must be considered as evils, what- 
ever may be the necessity for employing them. 

1590. I admit, that society suffers but little loss on account of " any 
individual child," so long as the loss is confined to that individual 
child ; but when this indifference to "individual" life goes beyond a 
single instance, we cannot foretell where it may stop — it may extend 
to thousands, for thousands are but aggregated units. 

1591. Dr. 0. concludes this remarkable essay in these words : "In 
estimating the value of the life of the unborn child at so low a rate, I 
most earnestly request the medical reader will never lose sight, that it 
is only in comparison with the mother, or when the child's life is put 
in competition with her safety, that any arguments on this score are 
entitled to the smallest weight. It is for the preservation of the mo- 
ther's life only, that w r e can justify the practice here recommended 
and insisted on." (p. 45.) 

1592. It does not appear to me at all necessary, that the value of 
the child's life should have so low an estimate, in order to have 
arrived at the above conclusion — it was every way sufficient for the 
purpose for which the comparison was instituted, that the value of the 
mother should have been deemed greater. I fear Dr. O. is charge- 
able with having done mischief, by the view he has taken of this 
subject ; for I do know full well, he has been quoted in support of 
" cephalotomy," where its necessity, in my estimation, was far from 
being absolute. 

1593. As no possible advantage can result from the manner in 
which Dr. O. has treated this inquiry, it is to be lamented that it was 
ever agitated, since the subject has not derived the smallest elucida- 
tion from it ; though it may occasion serious, and often repeated mis- 
chief. Had he treated this matter differently, and shown how 
precious the life of a child is, yet, however precious, that that of the 
mother is still more so ; and that nothing but imperious necessity 
should be permitted to institute a comparison of their respective 
values, when one or other must be the sacrifice, it would, in my 
opinion, have more certainly served the cause of humanity, and much 
more effectually have promoted the interest of science. 

1594. I shall pursue this subject a little farther, by offering a few 
remarks upon " Elizabeth Sherwood's case," by which Dr. 0. sup- 
poses he has ascertained the minimum opening of a pelvis, through 
lyhich a child at full time may be extracted by the crotchet. 



CEPHALOTOMY. 485 



Observations , fyc, on Elizabeth Sherwood's Case, as related by Dr. 

Osborn. 

1595. The whole of Dr. Osborn's arguments on the subject of 
" embryulcia," are intended to show, 1st, that this operation deci- 
dedly merits the preference over the Cesarean section, wherever 
there is an inch and a half of opening at the superior strait; and 
2dly, that it is never justifiable to perform the latter operation when 
a diameter of this size really exists; these positions he attempts to 
illustrate, by the recital of the melancholy case of Elizabeth Sher- 
wood. 

1596. The comparative merits of these two operations should alone 
be decided by the advantage one may possess over the other; and 
this advantage determined by the general results of the respective 
operations. Dr. O. condemns without reserve the Cesarean section, 
as consigning the woman to " inevitable destruction," while a num- 
ber of equally respectable men recommend it in preference to the 
crotchet; affirming it to be equally safe, and decidedly more advan- 
tageous, as the child has a chance of life. I shall, however, reserve 
my consideration of this subject, until I speak of the Csesarean opera- 
tion itself; and shall now proceed to make a few observations upon 
the case on which Dr. O. is determined to rely for the support of his 
opinions upon this point. 

1597. Elizabeth Sherwood's was a case of extreme deformity; she 
was but forty-two inches in height — she could neither move nor stand, 
but by the aid of crutches. In her 27ih year she became with child, 
and was admitted, for the purposes of delivery, into the Store Street 
Hospital, London. After her labour commenced, it was at first con- 
templated to perform the Caesarean operation, as " there would be a 
certainty of preserving one life at least." But this humane and proper 
determination was abandoned, it would seem, with as much facility 
as cruelty, because Dr. 0. and his friends " were rather disposed to 
believe that the child was dead." 

1598. Not a single reason is given for the "disposition to believe 
the child to be dead'''' — nor were they satisfied themselves that this was 
the case, from the doubtful and careless way Dr. 0. has expressed 
himself on this point. It was due to the public, to the profession, 
and to themselves, to have stated at large, the grounds of this belief; 
and, if they were well founded, the operation, which soon after com- 
menced, would certainly have been justifiable ; if the child were not 
dead, it might admit of doubt. However, the opening of the head 
was decided upon ; and the child was ultimately delivered. It is 
upon this delivery, and the state of the pelvis, as declared by Dr. O., I 
propose to offer a few remarks which suggested themselves by care- 
fully reading the case, but which created strong doubts of the fidelity 

42 



486 CEPHALOTOMY. 

of the representation;* for if the case he faithfully related, it almost 
disposes us to say, he had performed impossibilities. 

1599. Dr. 0. commences his account of the examination of this 
poor woman, by stating, " that immediately upon the introduction of 
the finger, he perceived a tumour equal in size, and not very unlike 
to the feel to a child's head." This was the projection of the sacrum, 
and so advanced towards the pubes, as to leave but a space of three 
quarters of an inch. On the left side of this projection, towards the 
ilium, there was a distance of about two inches and a half; leaving 
a space of three-fourths of an inch. On the right side there was 
rather more than two inches ; with an opening in its widest part of 
one inch and three quarters; gradually, however, narrowing each 
way. So much of the pelvis. 

1600. From the data here given, both the superior and interior 
straits must have been faulty — the lower, t presume, to such a degree, 
(though nothing of the kind is mentioned,) that the hand could not 
be introduced; or, at least, not easily; since the projection of the 
sacrum was " in size and feel like a child's head ;" consequently, 
there must have been extreme difficulty in ascertaining the situation 
of the head, either as regards its position or firmness ; for the finger 
could not reach so high without the introduction of the hand. 

1601. He next informs us, "the os uteri, though but little dilated, 
was soft and flabby ;" " the membranes were not yet broke, but with 
some difficulty he perceived the child's head, through them, situated 
very high above the projection." From whence did the difficulty to 
touch the child's head arise ? its remoteness — the hand then could not 
have been introduced into the vagina, or this " difficulty" would not 
have existed. In an examination so important to the welfare of his 
patient, it is presumable that Dr. 0. would have introduced his 
hand, had this been practicable. I shall employ this conclusion pre- 
sently. 

1602. Next morning " no alteration had taken place either in the 
state of the os uteri, or the position of the child's head." The mem- 
branes had given way during the night. Dr. O. now availed himself 
of the opinions of several celebrated accoucheurs and surgeons, neither 
of whom gave greater dimensions to the upper strait than had been 
given by him ; some even less. The Caesarean operation was first 
suggested ; but abandoned, as stated above, without any apparent 
good reason. 

1603. Dr. 0. now commenced the operation of " embryulcia," and 
says, (i even the first part of the operation, which, in general, is suffi- 
ciently easy, was attended with considerable difficulty, and some 

* In this remark, I am by no means to be understood to insinuate, that I call into 
question the veracity of Dr. O. . I merely suggest, that as mathematical precision 
could not be arrived at, an error in estimate may have crept into the account; since 
from the great interest which was excited, as well as the confusion consequent upon 
an operation under sirch circumstances, extreme accuracy could not, perhaps, reason- 
ably be expected. 



CEPHALOTOMY. 487 

danger." From whence arose the danger? the wounding of the soft 
parts of the mother, I presume. " The os uteri was but little dilated, 
and was awkwardly situated in the centre, and most contracted part 
of the brim of the pelvis " — that is, where there was but a space of 
three-fourths of an inch. " The child's head lay loose above the brim, 
and scarce within reach of the finger, nor was there any suture directly 
opposite to the os uteri." Would it not seem to require an unusual 
perfection in the. tact, under such circumstances, to satisfactorily de- 
termine there was no suture opposite the os uteri? — probably there 
was none; but to ascertain and satisfy ourselves, as Dr. 0. appears 
to have done, would require, as I have just stated, an uncommon 
degree of nicety of touch ; for it must be borne in mind, there was no 
pressure at this time on the head to make the bones ride over each 
other, and by which the presence of a suture might be detected or 
even suspected ; on the contrary, " the head lay loose above the brim, 
and scarce within reach of the finger. 

1604. I grant, however, it is not fair to suppose that one cannot 
do that, which another would find impossible. Yet I must consider 
myself safe in the remark, that a little pressure from the finger, and 
some resistance from the head, would have been essential to the dis- 
covery of a suture, had one even been there. 

1605. Dr. 0. proceeds to say, " he desired an assistant to compress 
the abdomen with sufficient force to keep the head in contact with the 
brim of the pelvis, so as to prevent its receding from the scissors, upon 
the necessary pressure of the point, to make the perforation ; I intro- 
duced them, with the utmost caution through the os uteri, and, after 
repeated trials, at length succeeded in fixing the point into the sagittal 
suture, near the posterior fontanelle." All this is so very circum- 
stantial, as to excite wonder, in no small degree — first, there was no 
suture opposite the os uteri ; 2dly, the os uteri was in the centre of 
the projection, and not well dilated, and at a part where there was a 
space but of three-quarters of an inch ; 3dly, the head was forced to 
keep its situation, that the scissors might enter; in which, after several 
attempts, he succeeded to penetrate a suture, and that " the sagittal 
suture near the posterior fontanelle!!" Now, I think I do not dis- 
parage the tact of any man, either living or dead, when I say, that 
none other than Dr. 0. could have told into which of the sutures he 
plunged his scissors under the same circumstances. 

1606. Dr. 0. now tells us of some of the difficulties attending 
his enterprise, arising from his attempts to break down the bones of 
the cranium: confessing that " the instrument at first invariably slipped, 
as often, and as soon as it was fixed, or at least before he could exert 
sufficient force for this purpose." It would be instructive to know 
what parts of the mother received the point of the crotchet " when it 
slipped ;" for we are forbidden, from the description of the pelvis 
itself, to suppose the point was guarded by the other hand, since it 
could not possibly be introduced profitably, (1601,) if at all into the 
vagina, for this purpose. 



488 



CEPHALOTOMY. 



1607. At length the Doctor succeeded in firmly fixing the instru- 
ment, even into, he believes, the foramen magnum, of which he availed 
himself " to the utmost extent, slowly, gradually, but steadily in- 
creasing the force, till it arrived to that degree of violence, which 
nothing could justify but the extreme necessity of the case." I would 
ask what must have been the condition of the soft parts against which 
this force was exerted ? I have known much less force than that 
" degree of violence which nothing could justify but the extreme ne- 
cessity of the case," followed by severe, and even hazardous, if not 
fatal consequences. But in this case Dr. 0. was ordained to triumph ; 
over not only nearly insuperable difficulties, but also over the con- 
sequences of the extreme violence he was obliged to use to accom- 
plish the delivery. In my hands, after such violence I am disposed 
to believe, nay, almost sure, the woman would have died; not so, 
Elizabeth Sherwood ; for she was reserved for another trial of a 
similar kind, and not being under the care of Dr. O. she died. 

1608. But, notwithstanding this great exertion of force, it was urged 
to no profitable purpose ; he therefore abandoned the idea of breaking 
down the base of the cranium by the crotchet, and then most happily 
succeeded in affecting by address, that which could not be overcome 
by force ; for, by a little management with two fingers, he was fortu- 
nate enough to place the base of the skull edgewise, which permitted 
it to pass, by a continuation of the force applied to it. Now, only 
let ns consider how wonderful Dr. O's achievement in this instance 
must have been : — first, he accomplishes the penetration of the skull, 
and the evacuation of the brain ; next, he succeeds in detaching by 
the crotchet e^ery part of the bones from the cranium, except its base, 
through an- aperture of one inch and three-quarters in width in its 
greatest capacity, and this gradually diminishing ; it had, however, 
rather more than two inches in length. Though this removal of the 
bones is not exactly expressed, it must be so understood, or he could 
not have turned the base of the cranium " edgewise." Soon after 
this, his difficulties were at an end, by the successive delivery of por- 
tions of the child's body, &c. 

1609. This case, from its success, is to serve as an instance of 
the triumph of skill and of perseverance over the greatest possible 
difficulties which can be well encountered in a labour ; and one as 
proving clearly and distinctly the superiority of the crotchet over the 
Cesarean operation, though the woman endured inquisitorial tortures 
with " surprising firmness and fortitude" for three hours, and most 
miraculously escaped with her life ! ! I say miraculously escaped — 
for who could, or who would anticipate success from such violence, 
under such circumstances ? I am persuaded, that neither Dr. 0. nor 
his compeers looked forward to such an issue, at the moment of its per- 
formance ; and it is nothing more, if the whole be faithfully related, than 
an instance of how much the human body can bear, and not an exam- 
ple from which either the young or the old practitioner, can safely draw 
conclusions in its favour. I have seen death follow the use of the 



CEPHALOTOMY. 489 

crotchet where there was neither the same degree of deformity, nor 
the violence necessary to effect delivery ; and where I believe a little 
injury was sustained by the soft parts, as the nature of the things per- 
mitted. I shall again have occasion to speak of the risks of embry- 
ulcia. 

1610. The mode of performing embryulcia is sufficiently simple, if 
we merely regard the opening of the head, and the breaking down 
the texture of the brain ; but the extraction of the bones in a confined 
pelvis is replete with difficulty, if we are sufficiently mindful of doing 
no injury to the soft parts of the mother ; and on this almost every 
thing depends. The head, if moveable at the superior strait, should 
be fixed, if the uterus, after the evacuation of the waters, does not 
contract with sufficient force to do this — the 1 point of Smellie's scissors 
must then be made to penetrate the cranium ; and if a suture can be 
found, it should always be preferred — when they are introduced as far 
as their shoulders will permit, the handles are to be separated to some 
distance, and : rotated in that situation, until an opening of sufficient 
size to admit the crotchet be made — when this is done, the crotrhet 
must be pa-ssed into it, and' the brain broken down with it. It is 
never necessary to use any other instrument foT this purpose.* When 
this done,, the point of the crotchet is to be fastened in the nearest 
portions of bone ; and it must, if practicable, be guarded by the fin- 
gers of the other hand against slipping — ff the bones collapse readily, 
and the pelvis be not much contracted, the head may pass nearly en- 
tire ; but if it is necessary to employ much force, the portions of bone 
on which the crotchet is fixed, will successively give way — the de- 
tached portions must be carefully removed' from time to time ; taking 
care not to wound the vagina in extracting them. 

1611. Dr. Osborn recommends the early use of this instrument, 
when it is necessary to employ it ; and' to permit the woman to rest 
for thirty hours, that putrefaction may take place in the child, as this 
will very much facilitate its extraction. Should the child have been 
dead some time before the operation, we need not wait so long, or- 
perhaps not at all. With a hope of diminishing the danger of cepha- 
lotomy, Baudelocque the younger has invented an instrument, " for 
crushing the head of the child dead in the body of the mother ; a new 
wav of terminating laborious labours. ' y ' It is called a: i( cephalo- 
tribe. ,: 

This instrument is said to be capable of reducing the head' of the 
child, when dead, to its smallest possible size, and thus avoid all the 
risk the soft parts of the mother incur, as well as protecting the prac- 
titioner from severe and sometimes even fatal wounds. The me- 

* Dr. Davis's craniotomy forcep* arc said to facilitate this operation very much — of 
this we can say nothing' practically. We refer the reader, with much pleasure, 
to a paper by Dr. Meigs, "On the Method of effecting Delivery in Cases of Defor- 
mity of Pelvis/' In this he will find some interesting and useful hints for terminating, 
such cases,. together with improvements in the instrum nts to be employed for this., 
purpose,. 

42* 



490 CRPHHLOTOMY. 

chanism of this instrument, from its great mechanical power, seems 
well qualified to crush the head after it has been seized by the blades 
of the instrument ; but here is the rub, in our apprehension: this must 
always be at some uncertainty ; as much so, at least, as the forceps, 
and all who have tried them, when the head has been at the superior 
strait, know the difficulty of using them ; but not so to those who spe- 
culate upon the use of these instruments in their closets. The in- 
strument, as far as we can judge of its modus operandi by a plate of 
it, seems well calculated for its intended purpose. It is extremely 
strong and heavy, weighing five pounds and a half ; a weight many 
times heavier than that of the forceps ; but this can be, in itself, no 
very serious objection ; as it is not to be made a companion of the 
accoucheur. — It is lauded much by Dr. M'Phail of Baltimore, who 
says he has known it to be employed " where the crotchet could have 
been of no avail:" which we confess we do not clearly comprehend ;. 
for it requires, for its use, as much space, at least, as the crotchet ; 
and consequently, this instrument (the crotchet) can be used wherever 
we should suppose the cephalotribe could. 

This instrument is restricted in its use to cases in which the child 
is dead, or believed to be so ; if living, the Cesarean operation is the 
only proper resource. 

Messrs. Boyer and Dumerel were appointed by the Royal Academy 
of Sciences a committee to examine the advantages of this instrument: 
their report is not exclusively in its favour; but Dr. M'Phail says, 
" its use is sanctioned by experience ; the danger apprehended from 
its application by Messrs. Boyer and Dumerel (high authorities) is 
entirely imaginary." JVous verons. 

Dr. M'Bhail states, with much propriety, the following truths, re- 
specting the use of the crotchet. " The danger attending the use of 
cutting and pointed instruments, in the practice of midwifery, is too 
well established to need any comment : the many deaths that have 
occurred from their use ; the many fistulas that have followed the in- 
juries inflicted by them upon the rectum and bladder ; the many lace- 
rations of the vagina and tearings of the perinseum : and last, though 
not the least, the gFeat risk run by the accoucheur of mortally wound- 
ing himself, during the manipulations necessary to their application, 
should induce us to hail, as a public benefactor, one whose fruitful 
genius has conceived and brought to perfection a means of obviating 
all these." 



Sect. IV. — d. Of the Ccesarean Operation. 

1612. This operation is proposed as a means, in cases of extreme 
deformity, to preserve the life of the child, or the mother, or both. 
The history of this operation offers proofs of success, as well as of 
failures ; and it appears to be agreed upon all hands, that nothing can 
justify its performance, but such cases as would require the use of the 



CESAREAN OPERATION. 491 

crotchet for their termination — the question then resolves itself into 
this : under extreme deformity, by which of the operations will the 
patient and society be most benefited ? 

1613. From an attentive consideration of both of these operations, 
I am in favour of the Cesarean operation, wherever there would be 
an absolute necessity for the use of the crotchet to the delivery of the 
child ; and for the following reasons: 

1614. First, because the child must inevitably be destroyed by the 
use of the crotchet. 

1615. Secondly, because, from all I can learn, and all that I have 
seen in the employment of this instrument in cases of extreme defor- 
mity, (though I confess my own experience in this business to be very 
limited,) the risk appears to be very great to the woman;* and, as just 
stated, certainly fatal to the child. 

1616. Thirdly, because there are cases in which it is impossible, 
at least in my opinion, even not excepting such as may have an inch 
and a half in the antero-posterior diameter, to deliver with the 
crotchet. 

1617. Fourthly, because where this instrument is employed, under 
the most favourable circumstances in which it would be justifiable to 
employ it, there is a constant and a great risk to the mother, with the 
certain sacrifice of the child. 

1618. In my remarks upon the choice of the crotchet, and Cesarean 
operation, I must always be understood to have reference to cases 
where it is ascertained, or is highly persumable, that the child is living ; 
for if the child be dead, and this satisfactorily proved, then the 
crotchet, under a sufficient diameter of pelvis,! should be preferred. J 
See chapter on the uncertainty of the child's death. 

1619. But if the child be dead, and the delivery impossible by 
the crotchet, the Caesarean operation should be proposed, as a dernier 
resource. 

16-20. Our opinions upon the propriety or danger of the Cesarean 
operation, will vary as we may consult the British or the continental 
accoucheurs upon the subject — the former declaring its invariable 
failure to the mother, though sometimes fortunate to the child ; while 
the latter assures us, it frequently succeeds with both. Whence 
arises this difference in result ? 



* Baudelocque, nephew to the late celebrate. 1 accoucheur, says that more than half 
the women die who have embryulcia performed. — Archives Generates dc Medecine, SfC. 
torn. xx\. Oct. 1829. 

t By a sufficient diameter, I mean, where there is at least two inches in lhc antero- 
posterior, and at least three and a I alf in the transverse; below this, delivery per vias 
naturales, I repeat, I believe it to be impossible. And it is a moot poit.t, whether, with 
a diameter of full two inches, &c.,thc risk to the mother is not as great as the Cesarean 
section, yet in this instance, and with a dead child, the ciotchtt would merit the pre- 
ference, as it is apparently the less severe operation, and one that would more certainly 
meet the public approbation. 

\ " But if the child be dead, nothing can excuse operations upon the body of the 
woman for the cxtractio ; oi a corpse." — Uwjrr and DumtiiVa Report. 



492 CESAREAN. OPERATION. 

1621. M. Tenon declared to> Dr. Garthshore,* that iaihis opinion the 
reason why it had so seldom, succeeded in Great Britain, was because, 
in that country, the operation is almost invariably deferred too long ; 
for the patient is suffered to be almost in artieulo mortis, before it is 
undertaken. 

1622. It is no* longer a* question among the continental accou- 
cheurs, which of the two operations is to be preferred, when there is 
an absolute necessity for either. The Caesarean section is almost ex- 
clusively adopted ; and the success attending it is sufficiently great, 
agreeably to the latest and best informed writers, to warrant this 
preference. Though the practice hkherto in Great Britain has been 
almost uniformly fatal, it is, nevertheless, considered a resource of 
the art by several of its most eminent men ; and they fail not to recom- 
mend it, whenever delivery is impracticable by this instrument ; and 
even where it might be effected, but perhaps at an equal hazard to 
the woman. Drs. Hull and Denman, and also Mr. Burns, may be 
considered as good authority upon this subject. Indeed Dr. Osborn, 
it would seem, had failed to convince his friend and associate, Dr. 
Denman, of either the superior safety of the crotchet in extreme de- 
formity, or of the invariable fatality of the Cesarean section ; for he 
has not quoted him as authority for the first, nor coincided with him 
in the latter. Dr. Denman decidedly favours the Caesarean section, 
under circumstances wherein Dr. Osborn would have proscribed it. 
And in some instances, Dr. D. is inclined to consider the operation 
in a* moral point of view : he queries, "Suppose a woman was so un- 
fortunately framed, that she could not possibly bear a living child by 
any method hitherto known. The first time of her being in labour, 
no reasonable person could hesitate to afford relief at the expense of 
her child : even a second and a third trial might be justifiable to as- 
certain the fact of the impossibility. But it might be doubted in 
morals, whether children should be begotten under such circum- 
stances, or whether after a solemn determination she cannot bear a 
living child, a woman be entitled to have a number of children de- 
stroyed for the purpose of saving her life; or whether, after many 
trials she ought to* submit to the- Caesarean operation, as the means of 
preserving the child at the risk of her own life, if she will submit to 
have children under such circumstances. This ought to be con- 
sidered." — Introduction, Francis's ed. p. 423. 

1623. Notwithstanding all that Dr. Osborn has declared in favour 
of the safety of the crotchet in extreme deformity of the pelvis, he 
appears to have carried conviction to the minds of but few ; and this 
unqualified assertion that the Caesarean operation is "inevitable de- 
struction"^ the mother, is almost daily contradicted by the promul- 
gation of successful cases. That it is an operation of great hazard, 
no one will deny ; but that it is necessarily fatal, has been contradicted 
by success, hundreds of times. 

* Hull's letter to Simmons. See par. 1615.. 



CESAREAN OPERATION. 



493 



1624. On the continent of Europe, this operation is resorted to at 
an early period of the labour ; before the woman is either exhausted 
by the continuance of unavailing pains, or is in a state almost of 
gangrene from fever. The uterus is cut before it is inflamed, and 
the child is extracted before it has expired; and the attempt to save 
both mother and child is sometimes crowned with the happiest result. 
Is there not, then, strong reason to believe, that, were the same inde- 
pendence exercised by the surgeons of Great Britain towards the poor 
woman who suffers from deformity, the same fortunate issue would 
happen as in France and Germany,* and as frequently? I am by 
no means of opinion that the failures, in England especially, have 
been owing to climate — procrastination is the cause of the evil. An 
interesting case is related in Rust's Magazine, w 7 hich we shall tran- 
scribe. 

Caroline Bechang was admitted into Graefe's Clinicum, in an 
advanced stage of pregnancy; she was thirty years old; much de- 
formed by rickets, and measuring four Rhenish feet in height. On 
the 20th September, after having been five days in labour at the full 
period, pains severe, and the os uteri dilated, she consented to the 
Csesarean operation. 

A little after two o'clock, Graefe passed the forefinger of his left 
hand, immediately below the umbilicus, and with a large scalpel 
made an incision downwards in the linea alba, to within an inch of 
the pubis ; dividing the entire parietes, and even penetrating the 
substance of the uterus. A second incision w r as made to penetrate 
the uterus, and expose the placenta, which, as had been anticipated, 
was found upon the forepart of the fundis of this organ. The assis- 
tants now firmly compressed the edges of the divided abdominal 
parietes upon the uterus itself, to prevent the protrusion of the intes- 
tines : in this they succeeded; Graefe carried his hand in a moment 
to the fundus ; separated the placenta with his fingers and thumb, and 
then withdrew it and the child almost together. The child was 
very active, and cried lustily. The uterus immediately and suddenly 
contracted, and the bleeding was inconsiderable ; for not more than 
twelve ounces were lost, and no ligature was required. The w r hole 
operation was completed in four minutes and a half. The wound 
was secured by three broad sutures and adhesive plasters, assisted 
by a bandage round the abdomen. The child weighed six pounds, 
and was well formed. 

During the operation the patient was sick, and vomited a little. 
In two hours she had pain and fever : V. S. 5xij. draught with ten 
drops of the aqua lauro cerasi was given, and it was repeated in a 

* In both these countries, this operation has been repeatedly performed, with the 
most entire success, and we, recently, have it in our power to congiatulate the profes- 
sion upon this operation being successfully performed both to mother and child, in 
several instances, by Dr. Locher and others. See Medico. Chirur. Trans. Vol. IX., 
&c.) In France and other parts of the continent, agreeably to Baudelocquc, one hun 
dred and thirty. nine women recovered, out of two hundred and thirty cade?. See Edin 
Med. and Surg. Jour. No. VI. New series.) 



494 CESAREAN OPERATION. 

few hours. The patient passed a quiet night. The symptoms ofpain ? 
inflammation, and fever, were threatening for some days but were 
promptly resisted by the lancet, by enemata, by narcotics, especially 
the lauro cerasus, hyosciamus, by fomentations, &c. By the ninth 
day, the wound had cicatrized, excepting a part near the symphysis 
pubis ; symptoms all favourable. 

The lochia were discharged regularly ; and in three weeks, she 
was able to sit up, and in three more was quite well. Early in No- 
vember she returned home with her child, both in perfect health. 

In Ferussac's " Bulletin Universal " for February, another case 
of the success of this operation is related ; it proved fortunate, to 
both mother and child. 

1625. We regret we are not more particularly informed of the cir- 
cumstances which created the necessity of this operation ; and espe- 
cially the condition of the superior opening of the pelvis ; at least 
as far as could have been ascertained upon the living subject. It 
may, however^ be fairly inferred, we presume, that the diameter of 
the upper strait was very small, from the great facility with which the 
child was extracted through the artificial opening made in the uterus. 

1626. In addition to these facts, and as a corroborative of the re- 
peated success of the Gaesarean operation, we will extract a case 
from the " Bulletin des Sciences," &c. for January, 1827. The 
operation was attended wkh every wished-for success, though per- 
formed on a woman who had suffered upon a former occasion ; the 
cicatrix, however, had always remained rather weak ; or more pro- 
perly, it had never entirely healed, and it continued to be rather thin- 
ner than other portions of the uterus ; it therefore gave way during 
labour, and subjected her to the operation of gastrotomy. 

1627. Two days were allowed to pass, before this operation was 
resorted to : it nevertheless proved successful as far as regards the 
mother, though the child was dead. The following history cannot 
fail to be acceptable, as the lives of both mother and child were 
saved by the timely and judicious performance of the Cesarean ope- 
ration. 

The operator in the following interesting case was Dr. Muller, 
physician of Lowenburg in Silesia. He was called in July, 1822, to 
visit a woman who had been two days in labour, and whom he found 
it impossible to deliver on account of deformity of the pelvis. She 
was thirty-three years old, only three feet tall, deformed in many re- 
spects, the legs and arms being disproportionately short, the fore arms, 
thighs and shins, somewhat crooked, the pelvis flat from before back- 
wards, the chest well constructed. The gravid' uterus projected very 
much. The whole body when he first saw her was bathed in perspi- 
ration, and she complained less of labour pains, than of insupportable 
and continual rending in the lower pelvis. The pulse was very fre- 
quent and small ; and the waters had been discharged for four-aod- 
twenty hours. On examining per vaginam, it appeared that the su* 
perior outlet of the pelvis was the form of a fissure, the length of 



CESAREAN OPERATION. 495 

which from the union of the os ilium and os pubis of one side to the 
other was four inches, and the breadth at each end between one and 
a half and one and two-thirds of an inch, at the middle between the 
prominence of the sacrum and symphysis pubis not above two inches 
and a sixth. The prominence of the sacrum gave the outlet the form 
of a heart posteriorly, and the shape of the anterior margin corres- 
ponding with that of the posterior. The os uteri had disappered as 
usual, and was close upon the upper outlet of the pelvis. The soft 
integuments of the child's head were pressed as far forward as the 
outlet would admit of, but the head was not wedged in. The integu- 
ments were elastic, and the mother declared she felt the movements 
of the child. 

Natural delivery was manifestly out of the question ; and the 
destruction of the child's head, though practicable, was fraught with 
danger to the mother, and besides, could not be immediately resorted 
to because the child was alive. Yet there was no time to be lost, 
as the woman's strength was greatly exhausted, and farther delay 
exposed her to the risk of speedy death. The Csesarean operation, 
then, appeared to be the only resource of art that remained. The 
patient readily gave her consent; and Dr. Muller, after the prepara- 
tory evacuation of the bowels and bladder, proceeded to perform it 
in the following manner. At the first incision, he cut through the 
integuments down to the tendinous expansion of the linea alba, be- 
ginning an inch below the navel, and ending an inch above the 
symphysis pubis. A small aperture was next made in the abdomen 
near the navel, the fore and middle fingers of the left hand were in- 
troduced into it, and the scalpel being then passed between them, 
the fingers and instrument were carried downwards till the requisite 
opening was completed. This was nine inches in length. The 
uterus now pressed forcibly forward, and many large vessels could 
be seen under its glistening surface. A part of the uterus was pinched 
up, and an incision, as long as that in the integuments would allow, 
was made through its parietes where they were most free of vessels. 
Very little hemorrhage followed the wound, and care was taken to 
sponge all the blood away so long as it continued to flow. As soon 
as the incision was completed, the child pressed outwards with its 
feet on the operator's left hand, and was immediately removed with- 
out difficulty. It was alive, healthy, vigorous, and weighed seven 
and a half pounds. The navel string was secured in the usual way, 
and the placenta soon afterwards was removed by introducing the 
hand previously cooled in water. During this part of the operation, 
pressure was made upon the abdomen to prevent the entrance of air 
into the cavity. The wound was now united by adhesive straps and 
covered with charpie; a fustian belt was then put on and tightened. 
At the lower angle of the wound, an opening, an inch in length, was 
left wiihout straps for the discharge to flow through. Meanwhile, 
the uterus was felt contracting in the usual manner, and formed a ball 
in the left flank. 



496 CJESAREAN OPERATION. 

A good deal of blood issued from the vagina after the removal of 
the placenta, and again after the dressing of the wound was com- 
pleted. The patient was directed to remain in the supine posture, 
and care was taken to make every arrangement before the operation 
to ensure perfect quiet for some time after it. In the evening, there 
was some fever, but no pain; and during the night she slept none. 
Next day the fever had increased, the pulse w T as very frequent, the 
thirst unextinguishable, the pain of the lower belly severe and con- 
stant, and she had snatches of sleep disturbed by startings; but 
during the night she slept well. During the third day the fever and 
pain were moderate, the abdomen a little swelled ; in the evening 
the fever increased ; at night she had little sleep. On the morning 
of the fourth, the fever was again moderate. The wound, which 
had suppurated, was dressed. In the evening, the usual febrile ex- 
acerbation occurred, with increased swelling, but little pain. The 
straps having become loose, they were carefully removed, and fresh 
ones applied. The edges of the abdomen were hot, swollen, and 
florid. The secretion of milk had commenced. At night, the patient 
slept well. On the morning of the fifth there was no fever, but it 
returned violently at mid-day, with smarting of the wound, and in- 
creased swelling of the abdomen. The fever moderated, however, 
in the evening, the lochia began to flow, and the patient again slept 
well. On the sixth, the abdomen was greatly swollen, the purulent 
discharge great, the pain considerable, and the lochia more abundant. 
In the evening her appetite improved and soup was allowed. The 
dressings were changed. On the seventh there was little or no fever, 
her appetite was good, the pain and swelling had abated, and the 
lochia more abundant. The wound was dressed, and it was found 
that two inches of it next the umbilicus had healed. From this time 
suppuration continued so profuse for some days that frequent dressings 
were required daily. The abdomen progressively diminished in 
size ; the fever was inconsiderable ; the appetite strong. On the 
eleventh, tonics were administered, the treatment having previously 
been confined to the occasional administration of a clyster. On the 
twelfth, the milk receded, and the pus had become less abundant, 
and of firmer consistence. On the sixteenth day there was not above 
an inch of the wound open ; the pus was healthy and moderate in 
quantity ; and the patient was able to sit up a little in bed. On the 
twenty-second, she was allowed to leave her bed for a short interval; 
but her debility was very great. For another week she continued to 
improve ; but for a few days after that, in consequence of her having 
removed to an uncomfortable lodging, and being restricted to an in- 
sufficient diet, the wound, which had nearly healed, became inflamed, 
and a black, fetid, rough, slimy fluid, was discharged from the belly. 
A change of quarters and diet, together with the use of cinchona, 
restored her former favourable state of progress ; and on the forty- 
third day the wound was completely closed. Some weeks afterwards 
the surface broke out again, but in no long time it was finally healed 



CJESAREAN OPERATION 



497 



up; and four years after Dr. Miiller saw her in good health, which, 
she said, had not suffered any interruption after the healing of the 
wound. The child died of convulsions when three months and a 
few days old.* 

1628. In fact, we may safely add, that in almost every Journal 
issued of late upon medicine, we find instances of success recorded, 
of both the Csesarean operation and gastrotomy. It will be seen, even 
from the imperfect recital made of the cases just related, that the sub- 
jects were not of the most favourable kind for these operations, yet 
they were followed by every contemplated success. Since this time 
the woman has been the subject of a similar operation, and with simi- 
lar success. 

1629. These facts should be duly appreciated, as they are of great 
practical value ; since they hold out strong inducements to imitation, 
when similar necessities present themselves ; and they offer resources, 
by which lives may be saved, under the most disastrous and unpro- 
mising circumstances. They, moreover, distinctly contradict the un- 
favourable reports against these operations, from the British medical 
writers in general, and of Dr. Osborn in particular. For were it true, 
as has been asserted by this gentleman, that the woman who suffers 
it "is doomed to inevitable destruction," it should be proscribed by 
the profession with one accord, nor should it ever be considered as a 
resource of the art, under any necessity, however imperious, when the 
life of the woman makes a part of the calculation. 

1630. But, on the other hand, if it be satisfactorily shown, that the 
success attending the Caesarean operation, in particular, is at least equal 
to its failures, (and of which, we think, no rational doubt can be en- 
tertained,) it should be regarded with less aversion, or rather viewed 
with equal complacency, with several other capital operations, in 
which necessity, rather than very frequent success, is pleaded in fa- 
vour of their performance. 

1631. This is especially necessary under certain conformations of 
the pelvis — namely, where the antero-posterior diameter of the supe- 
rior strait is less than two inches and a half. In such a case, we are 
persuaded, that, delivery by the crotchet offers an equal risk to the 

* Since the above was written, a successful case of the Csesarean Section has been 
performed by Dr. Gibson ; we shall merely give an outline of it, referring the reader 
to two sources for farther information — to Dr. Nancrede's account in the American 
Journal of Med. Sciences for Aug. 1835, and to Dr. Gibson's Surgery. 

Mrs. was taken in labour on 24th March, 1835 ; it was decided from previous 

experience, she could not give birth to a living child. Premature labour was offered 
and rejected; the gentleman was unwilling to immolate so many children (three) by 
Cephalotomy, and agreed that no other chancu was left but the Caesarean Section ; she 
consented to the alternative, and Dr. Gibson performed the operation most happily. 
The reward was, a living female child, and a living mother, and both well to this 
moment, 12th Nov. 1835.* See American Med. Jour, of Med. Sciences, for Aug. 1835. 

• Thii operation has been performed on the same subject wilh the same gratifying results, by the 
same gentleman. See Dr. Fox's account in American Med. Journ. of Med. Sciences, for May. 1838. 

43 



498 CESAREAN OPERATION. 

mother, as the Caesarean operation, with the absolute destruction of 
the child. 

1632. The Caesarean section is recommended only when the child 
cannot be delivered without the mother incurring at least an equal 
risk from the employment of the crotchet — this being the case, it 
should be w r ell and satisfactorily ascertained that there is sufficient 
roOm to permit the base of the child's cranium to pass without diffi- 
culty.* I have already stated (note to par. 1618,) the space I think 
absolutely necessary to this end; therefore, I should not think it 
justifiable to sacrifice the child for the bare possibility of its being 
delivered per vias naturales, and have, if it fail, no alternative but the 
Caesarean operation. I must therefore repeat, and it is also the opi- 
nion, I am happy to state, of Hull, Hamilton, and Johnstone, that Dr. 
Osborn has fixed his limit considerably too low. 

1633. For what reprehension, indeed I had nearly said punishment, 
would be sufficiently severe for that practitioner, who, after having 
destroyed the child, should find it impossible to deliver it; and then, 
for its accomplishment, subject the poor woman to the Caesarean sec- 
tion.! Besides, we have met with a case in which it was impossible 
to introduce two fingers into the vagina, owing to the approximation 
of the rami of the ischii. They ran parallel to each other through 
their whole length, and left but a chink of half an inch in width ; the 
point of the coccyx so much intruded in the lower strait, that there 
was but an inch between its extremity or point and the pubes. So 
that if two fingers could gain admission into the vagina, they could 
advance no farther as they would immediately be opposed by the 
point of the coccyx and the posterior surface of the ossa pubes : here 
it would be impossible for even the crotchet to be applied, and the 
woman would have died undelivered as she did, because her physi- 
cians would not take the responsibility of the Caesarean operation. It 
is strange that men, could wait patiently and see a poor creature die, 
rather than incur the risk from an operation, by which hundreds had 
escaped an untimely grave. 

1634. Some have insisted, that this operation should never be per- 
formed upon the living woman, let the exigency of the case be what 
it might — to this Dr. Denman makes the following judicious remarks : 
" Impressed, perhaps, with the dread of the operation, they did not 
distinguish between necessity and eligibility, and therefore wished to 

* Now, as this portion of the child's head is always of nearly the same density and 
bulk, and always, perhaps, retained from its size, it will at once be perceived how 
difficult and dangerous the attempt must be to transfix or commute it by a sharp 
pointed or cutting instrument within the uterus, and above the upper opening of the 
pelvis, especially as it is not practicable to fix it so firmly as to permit a pointed or 
cutting instrument to pierce and break it. It was the knowledge of these dangers and 
difficulties that made M. Baudelocque exert his inventive faculties, and form his ce- 
phalotribe, which, it is declared, will break it up into fragments. See p. 577, par. 
1611. 

t This must not be looked upon as a gratuitous position — for the case has occurred 
more than once. The latest instance we have met with occurred in 1823. 



CESAREAN OPERATION. 499 

abolish it altogether, which would be an unnecessary and improper 
general rule. But if it were to be performed only when the patient]was 
dead, more particularly if we were to wait for her death, as the only 
proper time of performing it, it would be fruitless. For I do not 
find any instance of a living child extracted by this operation after 
the death of the mother,* unless the child escaped by the same stroke 
as that which proved fatal to the mother, of which the accounts seem 
to be almost fabulous, or merely accidental. Yet, as in cases of wo- 
men dying suddenly in convulsions, hemorrhages, rupture of the 
uterus, or other rapid diseases or accidents, at different periods of 
pregnancy, or of labour, it is possible for a living child to be extracted 
after the death of the mother, by speedily performing this operation ; 
and as no harm can possibly result from the operation, supposing our* 
selves disappointed, no reasonable objection can be made to our per- 
forming it under such circumstances."! 

1635. I might ask, what degree of turpitude, or if any, should at- 
tach when a woman is permitted to die, knowing she must die, if not 
relieved, if the only alternative in such case be neglected to be made 
use of, however hazardous ? What is it that renders this operation 
so dangerous ? to this kind of query Dr. Denman remarks — 

1636. " In almost every case in which this operation has been per- 
formed in this country." (Great Britain,) " the patients have died. It 
may be of use to inquire whether their deaths were occasioned by any 
disease with which they were afflicted before the time of labour : 
were the consequence of the state to which they were reduced from 
the occurrences of labour, before the operation was performed ; or 
were the inevitable consequences of the operation. In cases of death 
occasioned by wounds, the following order, in which the danger is 
produced, may be observed: first, from convulsions, or immediate 
loss of blood ; secondly, from inflammation ; thirdly, from gangrene ; 
fourthly, from excessive, or long-continued suppuration, under which 
the patient becomes hectic. Though almost all the patients on whom 
this operation has been performed, died, their death happened at dif- 
ferent periods ; but not one died, either while the operation was per- 
forming or immediately after it. No convulsions were brought on by 
incisions ; nor does it appear that any of them sunk through the loss 
of blood accompanying or succeeding the operation. If we may 
judge of the cause of death by the time of the patient's dying, it 

* There are two instances, within a few years, of this operation bring performed 
after the death of ihe mother with success to the child One of these was after a 
flooding. {Phil. Med. $ Phys. Jour. No. IT. p. 189.) The o'her after death from 
dysentery. (Jour. Univers. des Sciences Med. for Oct. 1822.) 

t I have been twice called upon to perform this operation after the death of the mo. 
ther. One had been a flooding case ; the other convulsions. In neither did I succeed ; 
owing probably to the great lapse of time after life had ceased in the mother. It should, 
notwithstanding, always be attempted under such circumstances, as the experiments of 
Dr. Williams, to determine the exact nature of the maternal foetal circulation, prove, 
tint in quadrupeds, the foetus is found alive a considerable time after the death of the 
mother : this also i-s the case most probably, in the hurmn subject. 



500 CESAREAN OPERATION. 

might be said that the death of those who failed within twenty-four 
hours, was, probably, owing not to the operation alone, but to the 
violence of this, combined with that of the previous disease ; but 
when they survived twenty-four or forty-eight hours, then thei? death 
might be attributed to the succeeding inflammation, in a body pre- 
disposed to disease. K we had the liberty of selecting a patient on 
whom to try the merits of this operation, we certainly should not 
choose one who was either very much distorted, or who had the mol- 
lites ossium, or who was evidently under the influence of some dan- 
gerous disease, or who had been several days in labour ; because the 
event must very much depend upon her state at the- time when the 
operation was performed." — Introduction, Francis's ed. p. 424. 

1637. Dr. Denman deprecates the conclusion, that he is attempting 
" to lessen the general aversion to this operation,'' and then remarks, 
" Every woman for whom the Csesarean operation can be proposed 
to be performed, will probably die ; arid, should any one survive, her 
recovery might be considered as an escape, rather than a recovery to 
be expected, though there is always a chance of saving the life of a 
child. But as such an escape may happen in any case in which the 
operation might be performed, we may and ought to esteem every case 
which can come before us, as the individual case in which a happy 
event is to expected. These conclusions will lead us to the principle 
of necessity as the sole justification of this operation, and urge us 
when we do perform it, and as far as may he in our power to select 
the most eligible time ; and from every motive, to exert all our judg- 
ment and skill for the service of the patient, as if we were certain 
she would survive," p. 425. 

1638. To this the doctor most feelingly and properly adds, " this 
operation can seldom be required ; and of course never will be per- 
formed on the opinion or judgment of any one person, unless in some 
ease of great and urgent necessity ; and a concurrence of opinions 
will afford the best security against its being performed unnecessarily ; 
and if it were to be presumed, by a subsequent measurement of the 
pelvis, and a new consideration of all these circumstances, that it had 
never been performed without such necessity ; that would prove only 
that the operation had been abused, and not serve as a valid argu- 
ment against its use when such necessity really existed," p. 425. 
This operation is apparently so cruel, that there is no danger of its 
ever being abused — not so the crotchet, it offers facilities for the con- 
cealment of mischief and of delivering the poor woman at the ex- 
pense of the life of the child ; that it will ever merit the preference, 
in the eyes of the ill-instructed. It will therefore be often performed 
most wantonly. A case that fell under the notice of the late Dr. 
James was of this description ; which we will relate in nearly his own 
words. " I was called into consultation with a young practitioner to 
a woman in labour with her third child ; he informed me that the 
woman had been in labour about six hours ; the waters evacuated by 
art ; the uterus opened to the size of half a dollar : but the labour did 



CESAREAN OPERATION. 501 

not progress as rapidly as he wished ; he opened the head hoping that 
would facilitate it. In this he was disappointed, after waiting several 
hours, he sent for farther assistance. When I arrived the poor woman 
was pacing the floor ; with the brai?i of her infant, soiling its surface ; for 
at each contraction of the uterus, (which were very violent) a quantity 
of brain dropped from it ; he (the practitioner) said upon similar oc- 
casions he had never met with so much difficulty ; that usually when 
tire head was opened, and the brain evacuated, that the child pretty 
soon followed." The Dr. after reading him a lecture on the subject, 
took his leave, as there was nothing to be done. He learnt after- 
wards that she was delivered in a few hours, and did well. 

1639. It is not deformity of the bones of the pelvis alone, which 
may give rise to the necessity of the Cesarean operation — this cavity 
may be occupied by tumours, or exostoses, so as to prevent the pas- 
sage of the child at full time, and which leaves no alternative but 
their removal, the crotchet or the section of the uterus. The same 
reasons which might induce us to have recourse to the Caesarean ope- 
ration, under a deformity of pelvis, in preference to the crotchet, would 
be valid in this state of the pelvis ; namely the impracticability of la- 
bour per vias naturales. And with respect to the removal of the tu- 
mours, it may be impossible, or so hazardous as to leave the choice 
in favour of the Caesarean operation. See a valuable Chapter on this 
subject by Mr. Burns, Midwifery, James's ed. p. 35. 



a. .Mode of performing the Cesarean Operation. 

1640. Having never performed this operation on the living subject, 
nor ever having seen it performed, I must rely upon the practice and 
experience of others, for the manner in which it should be done. 
For this purpose I have examined with care the various plans pro- 
posed for this operation ; and think that the method proposed b) 
Baudelocque unites more just and rational views than any other I have 
met with. I shall, therefore, recommend it to be followed, should 
a necessity present itself for its adoption. 

1641. He says, " The Cesarean operation, like many others, has 
a time of election, and one of necessity: the latter always takes place 
when the waters are evacuated, except as circumstances foreign to 
those which oblige us to operate, present more urgent indications. ,, 
This necessity is also created, he says, by the woman's sudden death, 
and the rupture of the uterus. See Chapter on the Rupture of the 
Uterus. 

1642. The time of election is, he thinks, before the rupture of the 
membranes, and as soon as the labour has begun, provided the neck 
of the uterus is effaced, and the os uteri sufficientlv open to transmit 

43' 



502 CESAREAN OPERATION. 

the lochia.* By operating at this time, agreeably to M. Levret, the 
extent of the incisions, both of the abdominal and uterine parietes^ 
will be less after the child is delivered. For it is very certain that an 
incision of six inches will affect a smaller number of fibres and ves- 
sels, when the uterus is still distended with the waters, than when it 
is strongly contracted on the child's body, and reduced a fifteenth or 
a twelfth part of its size. 

1643. He recommends two bistouries to be employed : one straight 
and probe-pointed, and one curved ; but this last is not necessary ; 
the common scalpel is better than the curved bistoury — there must be 
at hand needles, ligatures, compresses, lint, fine linen, brandy, &c. 
The woman must be placed on a pretty narrow bed, of sufficient 
height, and the bed should be the one on which she is finally to lie, 
that she need not be disturbed after the operation. The bed should 
be so protected, as to prevent its being wetted by the discharges, and 
when the cloths are withdrawn, to leave the woman dry. She should 
be laid upon her back with the legs and thighs extended while the in- 
cision is made ; and half bent, during the extraction of the child. 

1644. He recommends, as do all the best writers upon the subject, 
that the incision be made in the Unea alba : when the part of the ab- 
domen is determined on, the urine drawn off, and the woman pro- 
perly placed, the abdominal teguments should be carefully cut through 
till the aponeuroses which form the linea alba are perceived. The 
linea albaf must now be cautiously divided, to discover the perito- 

* In Germany, the time chosen for the operation is similar to that recommended by 
Baudelocque ; that is, when the mouth of the uterus is opened, and before the waters 
are discharged. 

t It seems from the researches of Dr. Mansfield into the antiquity of this operation, 
that it is much older than has been admitted by Osiander, Kurt Sprangel, and some 
others. For he informs us, that in the Thalmud, one of the oldest works among- the 
Jews, and the production of the most learned among that people at that time, this ope- 
ration is not merely indicated, but distinctly mentioned in the following words : " In 
a case of twins, neither the first child which shall be brought into the world by cutting 
into the abdomen, nor the second can receive the rights of primogeniture, either as re- 
gards the office of priest or succession of property." 

The indications for this operation are not pointed out. Again, in a work called the 
Nidda, which is looked upon as an appendix to the Thalmud, it is stated, in allusion 
to the time the husbands must abstain from their wives after delivery, that " it is not 
necessary for the woman to observe the days of purification after the removal of the 
child through the parietes of the abdomen." 

The conclusion is irresistible, that the Cesarean operation was known at that time; 
and that it was frequently performed upon the living subject ; and more especially as 
there are several controversies respecting the necessity fir women who have suffered 
this operation to observe the days of purification.. 

The same authority also proves, that the cutting into the linea alba is not the oldest 
mode of performing this operation, as supposed by Osiander; but that operating in the 
3ide claims the priority, as Maimonides, who wrote a commentary on the Nidda, de- 
clares certain words to mean, that " a woman, who cannot bear a child in the natural 
way, shall be opened in the side, and in this way delivered of her offspring." 

The mode of performing this operation, is in the words of Salomo Jarhi, one of the 
learned commentators upon the Nidda ; "the abdomen," he says, "must be opened by 
Samm, the child extracted, and the parts healed." Samrn, in this passage, is said to 
signify an instrument, which was sufficiently sharp for the division of various parts. 

It seems, that, with the ancients, the operation was always performed on the side ; 



CESAREAN OPERATION. 503 

naeum, in which a small opening must be made. A finger of the left 
hand must be introduced into this hole, and the abdominal teguments 
a little raised by it to prevent any of the parts within getting injured 
by the instrument, for which this finger serves as a director. 

* 1645. The first incision must extend from the umbilicus to within 
an inch or an inch and a half at most, of the symphysis of the pubes. 
This, he says, is a little longer than it is usually made, but the uterus 
is better discovered by it, and it can in consequence be opened nearer 
to the fundus. He thinks the peritonaeum is better opened from above 
downwards, taking care to go along one of the sides of the bladder, 
when this organ rises up too high, as sometimes happens. 

1646. The uterus should be fixed by the hands of an assistant, by 
pressing a little on the sides, and another make a similar pressure 
abore the umbilicus, in order to circumscribe the uterine tumour, and 
hinder the intestines from presenting at the wound. 

1647. Professor Graafe believes he has diminished the dangers of 
this operation by the manner in which he conducts it, of which the 
following is a summary: — The operation should be performed if pos- 
sible at the full period of utero-gestation, and at the time labour has 
commenced ; the incision should be made through the linea alba, 
below the umbilicus, and should extend five inches ; the incision into 
the uterus should be four inches six lines in length. To prevent the 

and the left was first chosen on account of the liver ; but afterwards it was performed 
on either side, as an opinion may have been entertained of the situation of the placenta. 
The incision was made on the external side of the recti muscles, and parallel to them; 
frequently it was carried in an oblique direction towards the pubes. The bleeding 
which attended this mode of performing the operation must necessarily have been 
very considerable, from the frequent wounding of the epigastric artery ; but yet it is 
a remarkable fact, that from 1500 to 1769, a space in which, according to Stein, eighty, 
two Csesarean operations were performed in this mode, only six turned out unfortu- 
uate. 

About the year 1770, some celebrated accoucheurs of Germany and France began 
to adopt the linea alba as the best spot for the incision. Delcurge was the chief per- 
son who showed the advantages which were to be derived from this mode of perform- 
ing the operation, by preventing the protrusion of the intestines and the loss of blood. 
Since his time, the linea alba is the spot generally chosen. 

Lauverjat soon after recommended that the incision should be made transversely; 
lie performed the operation in this manner twice with success. He proposed to make 
the first incision between the recti muscles and the spine, just below the third false lib, 
at the point towards which the uterus projects: other modes have also been suggested. 

It is, however, agreed, by all the best continental accoucheurs that neither of ihe 
modes proposed is applicable in every case, owing to the structure of the integuments, 
the situation, form, and projection of the uterus. If structure only be regarded, the 
linea alba presents the greatest advantages. But advantageous as it is, Dr. Shcnk 
thinks it cannot always be chosen. And the rule now on the continent is, to cut op- 
posite to that pari where the projection of the uterus is the greatest. 

The reasons assigned for this are, t 'at the integu n< nts of the abdomen lay closet 
to the gravid uterus, whilst the omentum and the intestines are pressed either above, 
or to one side, so that an assistant can very readily prevent them (rom protruding in 
the way of the operator. 

In England, the linea alba is generally chosen for the performance of this opera- 
tion ; and it appears to be the best, as less hemorrhage follows, and there is a greater 
facility of producing adhesion here than in other parts. With good assistance, it is 
thought protrusion may always be prevented, by employing large sponges instead of 
the hands. — Edin. Med. and Surg. Journ. No. IX. New Series. 



504 CESAREAN OPERATION. 

escape of the intestines through the external incision or wound, Dr. 
G. advises the employment of large pieces of sponge, prepared with 
wax, each one foot long, six inches broad and nearly three inches 
thick. Three such pieces are necessary for one operation. They 
should be applied to the abdomen, so as to leave for the incision a 
space eight inches long, by three or four wide, and are to be retained 
by two or three assistants, who should make moderate pressure with 
the hand ; care being previously taken, that every portion of intes- 
tine has been removed from the place reserved for the incisions. 
Pressure on the sponge will then keep the bowels at a distance, 
and prevent their escape. If the placenta be not completely 
detached, it should be removed by the surgeon, in preference to its 
remaining in the uterus. The edges of the wound in the abdomen, 
should be kept in contact by sutures made with very soft ribands, 
eighteen lines in width, and with flat needles with two cutting 
edges. Three sutures, thus effected, are as advantageous as six 
others with a simple thread. Farther, to secure the lips of the 
wound, four or five adhesive straps are necessary ; each eighteen 
lines in breadth, and long enough to pass once and a half round the 
abdomen ; the middle being applied to the back, and the extremities 
crossing in front, above, below, and between the sutures. After the 
operation the mother demands rest, and sedatives, as laurel water, 
extract of henbane, or the infusion of belladonna, to be administered 
as an enemata. When inflammation ensues, the loss of blood is the 
best remedy ; salts and calomel do not answer. If nervous symp- 
toms arise, opium, with the others, in small and repeated doses are 
useful, while attention is to be paid to the lochia! discharge, and 
the mammary secretion. In the management of the wound, the 
sutures, and the kind of suppuration demand attention, especially at 
the inferior portion of the wound. The adhesive plasters ought to 
be continued for a long time. (The North American Med. and 
Surg. Jour. No. IX.) 

1648. The abdomen being opened to a convenient extent, a little- 
stronger pressure is to be made above the umbilicus, to bring the 
fundus of the uterus nearer to the superior angle of the wound; it is- 
then to be opened in the middle of its anterior part with the scalpel, 
until the membranes are discovered. An opening, only large enough, 
to admit the finger, should be made into them, taking care not to 
wound the child; the forefinger is then to be passed into their cavity, 
as a conductor for the bistoury, with which the uterus must be 
opened, cutting from within outwards, as was done with the tegu- 
ments of the abdomen. 

1649. This incision in the uterus must be extended at least as high 
as the superior angle of the external wound, terminating it below an 
inch and a half, or thereabouts, above the inferior angle of it. The 
extent of this incision must be determined in some measure by the 
size of the child, which is supposed in general to be such, as will in 
its small circumference, measure ten, or ten and a half inches. An 



OJESAREAN OPERATION. 505 

opening, then, of five or six inches is generally sufficient; but it is 
better to make it larger than smaller, to avoid tearing the angles of 
the wound, when the child passes it. 

1650. Should the centre of the placenta present itself under the 
knife, it must be cut ; but if the edge is found in the neighbourhood 
of the wound, it is better to detach it in order to open the mem- 
branes. 

1651. When the uterus is properly opened, the hand must be 
passed into it, and the feet searched for and brought out — proceeding 
as if a child were to be delivered footling. This rule must be ob- 
served, except where the head presents naturally to the wound of the 
uterus ; if it be not expelled speedily by the natural contractions of 
the uterus, its exit may be favoured, by a slight pressure upon the 
sides of the belly of the woman, and at some distance from the inci- 
sion, or by insinuating the forefinger of each hand, under the angles 
of the lower jaw. 

1652. The placenta is soon expelled by the natural powers of the 
uterus forcing it towards the wound ; this may be favoured by gently 
acting upon the cord, or by taking hold of the edge of the placenta 
with the fingers, so soon as it may present itself. Care should be 
taken to remove any coagula that may have formed within the uterus, 
and a finger passed through its neck, to force any thing that may have 
formed in it into the vagina. If the uterus remain soft and inactive 
after the removal of the placenta, it must be gently stimulated ex- 
ternally by the fingers, to oblige it to contract. 

1653. But little blood is lost when the uterus is cut in the centre 
of its anterior face, unless the placenta be attached there, and even 
then the discharge is but of short continuance, if this organ contract 
forcibly. A bleeding may supervene some hours, or even days 
after the operation — by exciting, however, the tonic contraction of 
the uterus, it will be put a stop to. 



b. Treatment* after the Operation. 

1654. The general indications presented after the operation, con- 
sist, first in the discharge of any foreign matter from the abdomen, 
which may have passed into it during the operation: this should 
be attempted before the wound is dressed, either by placing the 
woman in a convenient situation, or by pressure applied to the sides 
above the hips. Sometimes warm water has been injected for this 
purpose. 

1655. The second is the dressing of the wounds, &c. — the wound 
in the uterus will require but little attention; since, if this organ 
preserves its powers, its contraction will lessen it one half, imme- 
diately after the operation, and would quickly heal, were it not for 
the passage of the discharges, which the uterus furnishes so abun- 
dantly the first few days after delivery. 



506 CESAREAN OPERATION. 

1656. The third, consists in preventing or overcoming inflamma- 
tion ; this must be attempted by a strict antiphlogistic regimen, con- 
fining the patient to barley-water, thin gruel, tapioca, rennet whey, 
&c. — forbidding, in the most earnest manner, all stimulating drinks, 
meat broths, &c. ; in a word, every thing animal or spirituous, unless 
some contra-indications may exist, or arise : in such case, the patient 
must be treated agreeably to the judgment of the practitioner. 

1657. It is thought by some, that in dressing the external wound, 
sutures are not absolutely necessary ; but surgeons of the highest 
character think it far the best method for securing the firmest and most 
solid cicatrix. Adhesive -strips will bring the parts very well together, 
but the flaccidity of the abdominal parietes prevents the exact coap- 
tation that is essential to a firm union. See par. 1647, &c. 

1658. It is admitted that sutures have their disadvantages, as they 
are sometimes obliged to be cut, or at least to be loosened, owing to 
the distention of the abdomen, or to give transit to coagula. The 
quilled suture is thought by some, to be the best ; but which ever is 
employed, care should be taken not to wound the peritonaeum in their 
formation. Sutures are to be so arranged as to permit the discharge 
of fluids from the wound ; they are, therefore, not to be unnecessarily 
multiplied. 

1659. This wound is thought to require more frequent dressing than 
any other penetrating the abdomen, in order to prevent extravasations, 
and the formation of clots, which the bandage retains within the lips 
of the wounds ; the dressings must be removed daily, or even oftener, 
if there be reason to suspect either protrusions of the intestines, omen- 
tum, or extravasations. The frequency of dressing, however, will be 
diminished, as the lochia may flow more abundantly through the 
natural passages. The dressings, agreeably to Baudelocque, should 
be very simple and without ointment. 

1660. It evidently appears, that there is much advantage in keep- 
ing up a free discharge of the lochia, through the os uteri ; and, for 
this purpose, several schemes have been proposed, such as a cannula, 
or hollow pessary, &c. I do not think this can be either an easy or 
a useful plan, and that the end could be much better answered by the 
occasional introduction of a very large-sized bougie ; this, I am dis- 
posed to believe, would not be attended with much difficulty — but I 
confess its recommendation is speculative. 

1661. It appears, however, to me evident, that some such contri- 
vance is practicable, and maybe well worthy the attention of one who 
may be under the dreadful necessity of performing this operation ; es- 
pecially, as Baudelocque declares it to be his opinion, that clearing 
the neck of the uterus from time to time, would render the Csesarean 
operation more certain. And in an operation of such magnitude and 
consequence, attention should be paid to the smallest circumstance, 
if it contribute to render it less fatal. 

1662. I have directed the patient to be restricted to the most rigid 
antiphlogistic treatment, (1656,) wherever there maybe inflammation, 



CJESAREAN OPERATION. 507 

or even a tendency to it : I repeat it here, that I may say, that with 
the same object in view, Baudelocque recommends the same plan ; 
but he, unfortunately, in his enumeration of the antiphlogistic articles, 
reckons veal and chicken broth ; both, or either of which, I would 
most positively forbid. He also recommends, that the patient should 
suckle her child if it be living ; if not, to have die breast drawn by 
glasses or puppies. 

1663. Baudelocque farther says, that " after the perfect consolida- 
tion of the wound, the woman should never go without a proper ban- 
dage, to prevent a subsequent hernia."* 

* Since writing the above, I received the following letter from my friend, Dr. W. 
E. Homer, Adjunct Professor of Anatomy in the University of Pennsylvania. The 
importance of its contents will amply apologize for its introduction: — 

My dear sir: — The Caesarean operation, as commonly pe> formed, puts into such 
danger the life of the mother, that it is still a desideratum to ascertain some modifica- 
tion of it, which may diminish its fatality, and thereby inspire the profession with 
more confidence and promptness in undertaking it. Several changes in it have been 
proposed from the time of its first adoption, principally with a view to avoid the chances 
of wounding the urinary bladder ; or of cutting through the large vessels, which, in a 
state of pregnancy, occupy the broad ligaments of the uterus. In their principle they 
differ materially from each other, as they all involve the necessity of cutting into the 
cavity of the peritonaeum, on which circumstance, it is generally conceded, the great 
danger of the operation depends. 

This operation has been a frequent subject of conversation which I have held with 
our common friend, Dr. Physic, and I have been as often instructed by the views which 
he has taken of it. More than two years ago, it being then a matter of particular 
inquiry with me, I was struck by the following propositions of his in regard to it, 
which made a very strong impression on me, and the justness of which I have ever 
since been extremely anxious to verify by dissection. It is well known to anatomists, 
that but a very small portion of the upper anterior part of the vagina, in the unim- 
pregnated state, is cove.ed by peritonaeum, and that the portion of peritonaeum which 
lies upon the fore part of the cervix uteri and vagina is connected to them by a long, 
loose, cellular tissue, which allows the peiitonreum, in the distentions of the urinary 
bladder, to be separated still farther up from the vagina. 

It has not been equally remarked, that this peritoneal covering of the vagina is of 
very fugitive character, and that in the moderate distentions of the bladder, the peri- 
tonBeum leaves completely the vagina, and applies itself to the bladder. It is also true, 
that if the distention of the bladder be much increased, the peritonaeum even leaves the 
anterior face of the cervix uteri, and its reflexion to the bladder departs thence at the 
lower part of the body itself of i he uterus. 

By a fortunate coincidence, I have at this moment under my observation these parts 
about the end or the sixth month of pregnancy ; the foetus having been just expelled 
from the uterus, with its head still remaining in the vagina, owin,r to a breech pre- 
sentation. It may be mentioned in passing, that there is good reason to believe that 
the uterus here took on the parturient action, after the other phenomena of life had 
ceased. In this case I find the peritonaeum drawn off from the vagina by a common 
distention of the bladder. And by my drawing moderately at the bladder, the peri- 
toneum leaves the cervix uteri after the same manner ihat it docs in the unimpregnated 
state. 

Dr. Physic, founding his ideas upon a similar observation made in early life, during 
the dissection of a pregnant woman, propo-es that, in the Caesarean operation, a hori- 
zontal section be made of the parietcs of the abdomen, just above the pubes. That the 
peritonaeum be stripped from the upper fundus of the bladder, by dissecting through 
the connecting cellular substance, which will bring the operation to that portion of the 
cervix uteri where the peritonaeum goes to the bladder. The incision being continued 
through this portion ot the uterus, will open its cavity with sufficient freedom for the 
extraction of the foetus. All of which the doctor supposed may be done by a careful 
operation, without cutting through the peritonaeum. 

It is evident that if this be a practicable operation, it will diminish immensely the 



508 ON PREMATURE DELIVERY. 



Sect. V. — e. On Premature Delivery. 

1664. About the year 1756, as Dr. Denman informs us on the au- 
thority of Dr. Kelly, there was a consultation of the most eminent men 
at that time in London, upon the morality and advantages which might 
result from inducing premature labour, in cases of deformity of the 
pelvis. The first case which was judged proper for the trial fell under 
the care of Dr. M'Cauley, and terminated successfully. Since this 
time, it has been so frequently repeated in England and elsewhere, 
as to satisfactorily establish its " morality," " safety," and " utility." 
This being the case, I shall not enter into its defence, as its frequent 
success places it above such a necessity ; but take its propriety for 
granted, and merely lay down such rules for its performance, as have 
been found from experience best, together with a few remarks upon 
these rules, en passant. 

Velpeau speaks both disparagingly and inconsistently of this ope- 
ration. He first informs us, that the view his brethren in France have 
taken of this operation, renders it criminal — for they have dogmatically 
assumed, that no one has a right to destroy a foetus at any period of 
utero-gestation, even (as we suppose) to protect the mother's life 
against the dangerous resources of the Sigaultian section, the Cassarean 
operation, embryulcia, or the chance of dying undelivered. For these 
are the only chances a woman can have, who has a pelvis so deformed 
as to render premature delivery eligible. 

He, however, appears immediately after to dissent from such a 
conclusion, and observes, " As regards myself, I avow, I cannot put 
in comparison the precious life of a foetus of three, four, five, or six 
months, a being scarcely differing from a plant, one that is bound by 
no ties to the external world, with that of the adult woman, whom a 
thousand social relations interest us to save : therefore, in a case of 
extreme narrowness of the pelvis, and where it was mathematically 
demonstrated, that delivery at the full period was impossible, I would 
not hesitate to recommend producing abortion, in the first months of 
gestation." In this sentence we discover a disposition to aid the 

tendency to peritoneal inflammation, and will, in fact, put it on a foundation of danger 
very closely allied to the taking up of the external iliac artery, near its origin, by 
turning aside the peritonaeum ; an operation, the success of which is sufficient to justify 
any competent person in undertaking it.* 

Knowing the value which you, as well as myself, put upon the suggestions of a 
person whose mind is so remarkable for its professional sagacity and resources, I have 
thought that even a proposition not yet confirmed by actual experience of its success, 
would not be an unacceptable addition to the fund of information you are about to 
communicate to the public. 

I remain, very sincerely, your friend, 

W.E. HORNER. 

To Doctor Dewees. Sep. 28, 1824. 

* Dr. Physic proposes that the operation be performed with a moderately distended bladder, and 
that a catheter should be introduced previously, to ascertain its situation. 



ON PREMATURE DELIVERY. 509 

woman by destroying the ovum in the early months of gestation. For 
what purpose is feeling exercised towards the woman but to prevent 
the use of the terrible resources of art under such circumstances at full 
time, and thus to save her life — so far, well — but Mr. V. immediately 
adds: u But it is altogether another thing, when there shall be two 
inches and a half at least between the pubis and the sacrum : as it has 
happened that the ovum has been expelled spontaneously, and the 
foetus born alive, therefore, the honour of art and of humanity unite 
in forbidding the us«i of any instrument, or any other attempt that 
might destroy the foetus." 

\Ve would ask. what proportion exists, of such escapes, to the victims, 
that such a recommendation of delay, would have? there would be at 
least a hundred to one, against the child being delivered by the na- 
tural agents either dead or alive, and the woman escape from either 
of the terrible resources for impracticable labour; as the Cesarean, or 
Sigaultian operations, or cephalotomy. 

He also declares, that " delivery, when induced previously to the 
seventh month, will necessarily Icill ; and it rarely fails to cause the 
death of the foetus, at the seventh or eighth." Now, this is evidently- 
assuming that which remains to be proved — namely, that the death of 
the foetus is inevitable ; for we are thoroughly convinced, that children, 
at an early period, have lived, spontaneously delivered, even as early 
as, or very little beyond the sixth month ; and as this operation offers 
a much better chance to the mother at either of these periods, even 
than embryulcia, which is generally considered the safest of these 
operations, it should be preferred, were the chances even fewer, in 
favour of the child. But at present, it is a matter of history, that the 
operation succeeds ; and this with very little danger to the mother ; there- 
fore, it is to be preferred in all such cases of deformity as forbid the ex- 
pectation or chance, of the child being born alive, by the natural powers. 
It would be difficult to fix the exact opening of the small diameter of 
the superior strait, and at the same time be able to determine the ex- 
tent of the transverse diameter of the child's head. Therefore, we 
can only make a general, or average estimate, of these diameters, as 
disease may change the structure in one, or as development more or 
less rapid or perfect may affect the other. Agreeably to Dr. Rams- 
botham, already quoted, the following rules may be permitted to 
govern ; " if the conjugate diameter measure 2£, or 3 inches, we may 
allow pregnancy to advance to the end of eight months; if 2J, or 
rather less, to seven months and a half; if 2\ inches, it must not pro- 
ceed beyond seven months ; if less than 2\ inches, it would be unsafe 
to delay beyond the seventh month ; and I would be inclined to induce 
labour rather sooner, because children have been reared at an earlier 
period." — Gazette, p. 437 . 

In another sentence, Mr. V. asks the following extraordinary ques- 
tion — " If it must be destroyed, (the child,) why not wait to the full 
period ; by doing so, we shall not destroy the few chances we have, 
of seeing a favourable termination of the labour." We are led to in- 
44 



510 ON PREMATURE DELIVERY. 

ier from this question, that Mr. V. thinks there is less danger from 
embryulcia at the full period of utero-gestation, in cases, where the 
embryo (agreeably to his phraseology,) must be destroyed, than even 
at an early period of pregnancy; a circumstance, in which he will 
not, we think, be borne out by any other practitioner — and for these 
especial reasons. First, if premature delivery be induced even after 
the sixth, or a little before the seventh month, the child must not, or 
does not necessarily perish. Secondly, that after the seventh, and 
from that to the eighth month, the chance for the child is increased, 
provided the diameter of the pelvis has justified so long a delay. 
Thirdly, because, if the case require the puncture of the ovum, it 
would be folly to wait to the term of labour, in expectation of any 
one chance u of a favourable termination of the labour," since the 
size of the child's head, if alive, and this is taken for granted, must 
necessarily increase the longer it remains in the uterus — for we may 
well ask in turn, how the chances for " a favourable termination " 
are increased, by a delay that will increase the evil, that renders the 
induction of premature delivery necessary; namely, an increase of 
disparity between the size of the child's head, and the pelvis ! Is 
this condition not admitted, (namely, that the head continues to aug- 
ment in size,) when he says, " if with a view of greater security (of 
the preservation of the child) the operation be deferred a fortnight 
more, what assurance can we have, that the head is not too large al- 
ready, to pass through the straits?" Traite Elementare de Part des 
Accouchemens. Tom. II. p. 807, &c. 

1665. Dr. Merriman has summed up within a very short space the 
laws which should govern in this case, which I shall introduce, with 
a few remarks. 

1666. " I. As the primary object is to preserve the life of the 
child, the operation should never be performed till seven complete 
months of utero-gestation have elapsed; and, if the pelvis of the 
mother be not too much contracted to allow of it, the delay of 
another fortnight will give a greater chance to the child surviving 
the birth."* 

1667. There has always been a considerable difficulty in ascertain- 
ing with precision the degree of opening of the superior strait. None 

* Dr. Merriman says, of forty -seven cases of premature labour, induced on account 
of deformity of the pelvis, nineteen have been born alive, and cap ble of tucking." — 
Med. Chi urg. Trans. Vol. 3, p. 123. Dr. Hamil'on, of Edinburgh, says ihat of twenty, 
eight cases of induced labour, twenty-four children were saved ! ! We must lake 
this proportion as being unique, and peculhr to this gentleman; for we believe, thero 
is none other instance of success equal to it. Dr. F. H Ramsbotham says thai much 
greater success has attended Dr. H's exertions than he can boasl of; but admits, th..t 
in more than one half of his cases the children were born alive, and might live to ma- 
turity. He performed the operation forty-seven times in twelve years. And lest this 
large number should startle or challenge belief, he states, that " the extensive charity 
that supplied the pi incipal part of these cases, embraces the districts of Spit tlefields 
and Bethnal. green, which parishes contain more deformed pelves than are to be met 

vvith over the s:ine quantity of square acres in any other put of this kingdon, (Great 
JBiitiio.) 



ON PREMATURE DELIVERY. 511 

of the inventions for this purpose can, perhaps, be sufficiently relied 
upon, to remove all doubt upon the question ; I am, however, of 
opinion that the calipers of Baudelocque are the best for this purpose, 
(79.) If the subject have been previously a mother, the s'rze of the 
pelvis may have been pretty nearly ascertained during the progress 
of the labour: if she have not been, it will be necessary to employ 
the finger, &c., to ascertain its condition as nearly as may be. 

1668. It would seem to be a rule founded upon experience, that 
no advantage would be gained by this operation, in a pelvis that had 
not two or two and a half inches complete, in its antero-posterior 
diameter, because a child at seven months would require an opening 
of that size to permtt it to pass ;* and it has been almost universally 
supposed, that a child which had not tarried " seven months com- 
plete " in the uterus, would not live after its delivery. This cer- 
tainly mnst be considered as a valuable, general rule : and if the state 
of the pelvis admit of farther delay, it would unquestionably be to 
the advantage of the child. 

1669. But what shall be done with such women whose pelves have 
rather less than two inches ? shall they be abandoned to the Cesarean 
section, or their children to the crotchet? either of these alternatives 
is certainly terrible ; and if nothing better present itself, must be sub- 
mitted to. It may, however, become a profitable inquiry, to deter- 
mine (from what has really happened upon other occasions,) the pro- 
priety of inducing labour at an earlier period than seven months ; say 
at six. Children have lived when delivered at this period, where 
there was no deformity of pelvis to contend with, (but this circum- 
stance, it is true, may occasion a different result,) and it perhaps would 
merit a trial in cases of more excessive deformity ; since, neither mo- 
ther nor child can have any greater injury offered them, than the 
dreadful operations just named. I have witnessed two instances of 
children living, (one indeed, at this moment alive, arrived at woman- 
hood, and mother of children, and the other lived several months,) 
the mothers of whom were, as far as could be ascertained, not more 
than six months advanced in gestation. "Mr. I. T. Cribbs relates 
the case of Mrs R., aged forty years, the mother of several children, 
who was taken in labour November 2d, 1827. Her last menstrual 
period was on the 15th of April, so that she could not be advanced 
more than twenty-eight or twenty-nine weeks. The labour continued, 
and the ovum was expelled entire, the membranes not having been 
ruptured, but still enclosing the foetus and liquor amnii. On breaking 
them, the child was found living, and perfectly formed. It was able 
to take the breast in a day or two. The child at six weeks old weighed 
two pounds and two ounces; at ten months its weight was twelve 
pounds. Although ' very weakly,' it is able to stand when leaning 
against a chair, and its health is not bad."f Indeed, the account 

* Madame La Chapellc has ascertained, that the transvese diameter of the child's 
head rarely or never exceeds three inches, and may be much less, -1GGG , 
t Lond. Med. and ^mg. Journ. for November, 1828. 



512 ON PREMATURE DELIVERY. 

which Fortunatus Licetus gives of his own birth, which was at be- 
tween the fourth and fifth month of gestation, may be given in evi- 
dence upon this subject, as it does not appear to be treated as fabulous 
by the writers on medical jurisprudence. In the case of Cardinal de 
Richelieu, it was decreed by the parliament of Paris that a child was 
" viable" at the fifth month. And Hippocrates has admitted that a 
child might live at six months and a few days. The rule of viability, 
if we may so term it, should be taken from the energy of the vital 
powers of the child, rather than from the term of utero-gestation. And 
I would be understood by the term viability, the capacity to sustain 
life, rather than the mere signs of this condition, by feeble cries, and 
languid movements of the limbs — for these may be exhibited by an 
abortion of the fourth or fifth month, but they will not, perhaps, pos- 
sess the capacity for future development at this early period. I say 
perhaps — for I would not wish to be thought to call in question the 
veracity of such authors as have declared in favour of this early date. 
My present impression is, and has been for many years, that children 
who have remained alive in the uterus until the sixth month, might, 
under favourable circumstances of labour, &e., be very often raised. 
This opinion is strengthened by a case which has lately occurred un- 
der my care. 

Mrs. B. was prematurely delivered on the 26th July, 1831, after a 
labour of very moderate force of six hours. She supposed herself 
advanced, beyond the seventh month. When the fcEtus was born it 
showed but feeble signs of life — it moaned rather than cried. It was 
not more than nine inches in length ; and it would not, I think, have 
weighed more than, perhaps, eight, but certainly not more than ten 
ounces. I had it enveloped in a pretty thick covering of carded cot- 
ton : its lips were frequently washed with sweetened water, and oc- 
casionally a little rennet whey was put into the mouth, which after a 
time it w T ould swallow. The meconium was purged off by the use 
of a little molasses and water. About the twelfth day it was put to 
the breast, which, after repeated trials, it was found it would draw 
feebly: this power, however, gradually increased, so much so, indeed, 
that at the beginning of the third week, it sucked very well. At this 
time I permitted the nurse to put a fine flannel dress upon it, and re- 
move the cotton. This day it is four weeks old — it is much improved 
in flesh, strength, appetite, and appearance — in a word, it gives every 
hope, that it will continue to thrive and do well. The successful issue 
of this case, so far, may be justly attributed to the fostering care of 
the friends of the child, and its nurse ; and the entire exemption from 
the fatigue of dressing it. 

1670. Dr. Hamilton's rule of " viability " being determined by 
weight, is altogether hypothetical — his minimum weight very conside- 
rably exceeds what we have witnessed. Now, one of the children 
alluded to above, weighed, at six weeks old, clothes and all, but one 
pound and three quarters. 

1671. It might be worth the trial, in cases where the choice is so 



ON PREMATURE DELIVERY. 513 

limited, as to leave no alternative, but the crotchet or Csesarean opera- 
tion. I am fully aware of all the contingencies attendant upon the 
proposition, yet it seems to hold out a remote chance to the child, 
without increasing the risk to the mother. I know full well how frail 
and tender the whole organization of the foetus is at this period ; and 
how many dangers await its delivery ; but, with me, they are not of 
sufficient force to destroy the possibility of success ; for the extreme 
pliability of the cranial bones at this period gives promise that the 
head may pass without the brain receiving so much injury, as to for- 
bid all chance of usefulness from the operation ; and if it succeed once 
in twenty times, it is certainly better than opening the head always ; 
or subjecting the mother to the other dreadful alternative. 

1672. " II. The practice should never be adopted, till experience 
has decidedly proved, that the mother is incapable of bearing a full- 
grown foetus alive." 

1673. "III. It is sometimes necessary to have recourse to the 
perforator in a first labour, though there may be no considerable dis- 
tortion of the pelvis; therefore, the use of this instrument in a former 
labour, is not alone to be considered as a justification of the prac- 
tice." 

1674. "IV. The operation ought not to be performed when the 
patient is labouring under any dangerous disease." And I would 
add, any very acute disease, if not absolutely dangerous. 

1675. "V. If, upon examination, before the operation is per- 
formed, it should be discovered that the presentation is preternatural, 
it might be advisable to defer it for a few days, as it is possible that 
a spontaneous alteration of the child's position may take place ; par- 
ticularlv, if the presentation be of the upper extremities." 

1676. I have introduced this rule, because I am not certain that it 
may not be an important one ; but to me, reason and experience seem 
to be against the fulfilment. Reason is against it ; because, the 
length of the child from the points of the nates to the top of the head, 
would exceed the transverse diameter of the uterus; and, therefore, 
it could not perform the movement called the " Somerset," which 
would be essential to such a change of parts. See Baudelocque, on 
the movement called " Somerset." 

1677. And experience, I am disposed to believe, must also be 
against it, since before the rupture of the membranes at full time, and 
when the mouth of the uterus is even pretty well dilated, it is very 
difficult sometimes to determine the part which may offer to the 
finger; I believe that no accoucheur, at full time, would positively 
pronounce on the part which may present itself to the os uteri, when 
the os uteri is but little expanded, and the membranes entire. And 
if he cannot at full time, when it must certainly be less difficult, and 
less hazardous, how can he, without a prodigious risk of being mis- 
taken, decide at seven months, when the neck of the uterus is not 
effaced ; and when it requires some force to pass the finger : when it 

44* 



514 ON PREMATURE DELIVERY. 

must be passed with great care and delicacy, that the membranes be 
not ruptured ; and where, did we employ a pressure sufficient to de- 
termine the nature of the presenting part, the membranes would 
almost certainly give way? I ask, under all these disadvantages, 
how can we ascertain with so much precision, as would render the 
examination free from doubt as to the suture that may offer to the 
finger? Dr. James gives us an instance in point, as regards the 
delicacy that is necessary in this examination: in this case the mem- 
branes yielded, by some little damage being done to the membranes 
by a previous examination. See his interesting case, Eclectic 
Repertory, Vol. I. p. 105. 

1678. An anonymous writer in No. II. of Vol. V. of third series of 
the New England Journal, has also questioned the possibility of 
ascertaining the precise nature of the presentation: or he rather 
declares, that " it is not very easy to do it, even in the earliest hours 
of a labour which takes place at the usual time, and after its most 
natural manner. Is it not then to be looked upon as almost impos- 
sible in the case supposed, (of premature labour artificially induced,) 
where the os uteri, having been opened merely by the finger, or a 
passage through it effected by a small instrument as far as the mem- 
branes ?" But, he adds, a it is not questioned that Denman, Burns, 
and Merriman, ascertained the presentation in the cases in which 
they waited before they broke the membranes." 

1679. I am, however, far from conceding so much to the tact of 
any man under such circumstances ; and for the reasons just stated. 
And, I may add, that in my opinion, it would be altogether impos- 
sible to discriminate between the head and the breech; or between 
the feet and the hands. Besides, it would be altogether unavailing 
to any useful end, to wait for a favourable change, were the presen- 
tation ascertained to be a preternatural one, agreeably to their ac- 
ceptation of the term ; as well as unnecessarily losing very important 
time ; for I agree perfectly with Baudelocque and Ramsbotham, that 
the change called the " Somerset," cannot take place after the sixth 
month of pregnancy. 

1680. I have insisted upon this view of the subject the more, be- 
cause the recommendation of delay comes from very high authority ; 
as well as from the most entire conviction that if it were acted upon, 
the moment for a successful operation would pass, not to return 
again.. 

1681. " VI. The utmost care should be taken to guard against an 
attack of shivering and fever, which seems to be no unusual con- 
sequence of this attempt, to induce uterine action, and has often 
proved destructive to the child, as well as alarming with regard to 
the mother. The peculiar circumstances under which the operation 
is performed, and the habit of body of the patient, will determine the 
accoucheur either to adopt a strictly antiphlogistic plan, or to exhibit 
opium or antispasmodics and tonics. 

1682. " VIL In order to give every possible chance for preserving 



ON PREMATURE DELIVERY. 515 

the life of the child, it will be prudent to have a wet nurse in readi- 
ness, that the child may have a plentiful supply of milk from the very 
hour of its birth." 

1683. The last direction would seem to intimate, that the woman 
who has undergone this operation, is incapable of nursing the child 
after it is borne — but this is certainly not so always. I have seen as 
abundant flows of milk after premature, (spontaneous, if I may so 
term them,) labours, as when the child was carried to the full time. 
Nor do I see any good reason, why an immature child should suffer 
more than a mature one, for the want of " breast milk" for a few days 
— yet the caution may be useful. 

1684. "Lastly. *i regard to his own cliaracter, should determine 
the accoucheur not to perform this operation, unless some other respecta- 
ble practitioner has seen the patient, and has acknowledged the operation 
as advisable." 

1685. It is not necessary to describe the mode of operating in 
this case ; for, as Dr. Denman very justly observes, " No person pro- 
perly qualified to decide on the propriety of this operation can be ig- 
norant of the manner of performing it." He cautions against in- 
juring the child in this operation — this cannot happen, if a blunt instru- 
ment be used instead of a sharp one. Dr. Campbell suggests with 
much good sense, that the less compression the child suffers in transitu, 
the less will be the risk it may suffer from uterine compression ; and with 
a view to diminish this, recommends, that the membranes should only 
be separated from the uterine parietes, by means of a large catheter, 
or the finger of the practitioner, as may from circumstances prove 
most convenient, instead of rupturing them, affirming that this 
operation will ensure uterine contraction as certainly, if not as 
speedily, as expending the liquor amnii, by puncturing the ovum. 
Ed. Med. and Sur. Journ. for April, 1830, p. 315. 

Professors Lovati and Belli, recommend the introduction of the 
sponge-tent, into the neck of the uterus, by means of an appropriate 
cannula or tube, gradually augmenting the size, about once in four or 
five hours, until the neck is sufficiently dilated ; at this time and even 
before, pains come on and the labour progresses until its final issue. 
Professor Lovati relates two interesting issues; so that in Italy, this 
practice is fully sanctioned by the above named professors. But we 
should prefer, were a case to offer itself to us, the plan just recom- 
mended by Dr. F. H. Ramsbothara, namely, the exhibition of the 
ergot. He relates six cases in which the labour was induced by the 
infusion of the secale cornutum. His mode of exhibition is to pour 
eight ounces of boiling water on three drachms of powdered secale 
cornutum, and simmer it for half an hour; strain, and give two table- 
spoonsful every four hours, until the uterine contractions are produced. 
—Lon. Med. Gaz. Vol. XIV. p. ±U. 

After admitting so much in favour of a premature delivery, in cases 
of such a degree of deformity as will not admit of the delivery of the 
child, without mutilating it, or subjecting the mother to hazardous 



516 ON PREMATURE DELIVERY. 

operations ; we should candidly confess the risks and difficulties that 
surround the necessary operation, especially to the child. For this 
exposition, we copy, with much pleasure, the temperate and rational 
details of Dr. F. H. Ramsbothara, as detailed in the 14th Vol. p. 406, 
of the London Medical Gazette. " Difficulties attending the object. 
The difficulties with which we have to contend with, in endeavouring 
to save the child, under the proposed plan, are certainly great ; and 
the following may be enumerated : First, The pressure on the navel- 
string may destroy its existence, as advanced by Baudelocque. There 
can be no doubt, that as long as the membranes are whole, however 
strongly the uterus may act, the pressure in the foetal body and funis 
is inconsiderable, owing to the quantity of fluid the womb contains. 
But as soon as the water is evacuated, when the parietes of the uterus 
come into close contact with the body of the child, it is very possible 
that the funis umbilicalis may suffer such injurious compression as to 
destroy the child's life, and this will, therefore, be looked upon as one 
of the chances militating against success. 

Secondly, " Children are more frequently found to present in apreter- 
natural position previously to the termination of gestation, than after the 
full time is completed. At a particular period of pregnancy, the foetus 
assumes a definite posture, from which it seldom varies. What this 
precise period is, I have no direct means of judging ; probably, it 
differs much in different cases ; but the fact is undoubted, that cross 
births are more frequently met with under the premature labour, either 
spontaneous or artificial, than in full-timed pregnancies. 

Of thirty-three cases which came under the knowledge of Dr. Mer- 
riman, in which premature labour was induced, fifteen presented pre- 
ternaturally, and only one of these children was born living. 

" The same observation, I myself made, though the proportion has 
not been so large ; for, of the forty-one children just alluded to, four- 
teen presented preternaturally ; and Dubois has recently stated, that 
in the Maternite, at Paris, out of one hundred and twelve children, 
born before the completion of seven months, in fifty-one cases the 
pelvis offered itself, and in five, the shoulder ; making a total of just 
one-half preternatural presentations. Thus, then, if the shoulder or 
breech present, we shall have little chance of saving the child ; be- 
cause, besides the ordinary cause of danger, — the pressure on the 
funis umbilicalis must be great when the head is passing the brim ; 
for, I presume, on there being a want of space to warrant a recourse 
to the means used. Mr. Barlow, indeed, states, that preternatural 
presentations are more frequently met with under distortion of the 
pelvis, than when that organ is well formed. His is a good practical 
authority, and this remark also coincides with my own observations. 
Until I became acquainted with Mr. Barlow's opinion, I looked upon 
this as on accidental occurrence ; and I do not yet know that it is 
regulated by any precise laws. 

" The third difficulty we have to contend with, is the chance of 
deception regarding the period of pregnancy, at which the operation 



SECTION OF THE PUBES. 517 

is performed. Women are very liable to be deceived in their reck- 
oning; they may fancy they have advanced farther than is really the 
case, and their representations may induce us to bring on uterine ac- 
tion before the foetus has acquired such a degree of perfection, as to 
enable it to sustain independent existence — or, on the other hand, the 
patient may have been pregnant before she -was aware of it: and we 
may delay the operation until it is too late, until the child is of too 
great bulk, and too strongly ossified, to pass through the particular 
pelvis the woman possesses ; and we may, consequently, in the end 
be compelled to resort to the operation of craniotomy ; as has occurred 
to myself in one instance. Though these difficulties, then, are some 
drawback to the success of inducing labour prematurely, yet they 
are, by no means, such as would induce us to discard the benefits 
it holds out. 



Sect. VI.— -f. Section of the Pubes. 

1686. I should not have enumerated this operation as one of the 
resources of the art, but to have it in my power to declare it not to be 
one — and though the operation has been performed twice, lately, with 
success, it is said, (that is, the children were born alive and did well, 
and the mothers recovered;) yet it is evident, from the relation of the 
cases, there could have been no very great deformity of the pelvis, 
or much room to applaud the operator for his " success." For after 
the operation, the patients were placed in warm baths, and the farther 
separation of the bones and dilatation of the parts were left to the 
efforts of nature. On delivery, the bones were found separated an 
inch and a half, a proof that there could not have been much restric- 
tion of the superior opening of the pelvis, as a separation of even two 
inches gives, as a general result ; but six lines, or half an inch, in the 
antero-posterior diameter of the superior strait ; therefore, less than 
half an inch must have been obtained in the cases just mentioned; yet 
with that additional capacity, the women were enabled then to deliver 
themselves: consequently, there could have been but little defor- 
mity. 

1687. Besides, it is stated, that in one of the cases no reunion of 
the bones took place, owing, it is supposed, to their not having been 
placed in apposition — this being so, one of two things must account 
for the defect ; either that the operation must have been most bung- 
lingly performed, not to have secured the bones in apposition ; or, if 
this be not admitted, there must be a risk of union not taking place, 
however well performed. 

1688. But as some have thought I dismissed this subject by two 
briefly noticing it ; and especially, as the cases glanced at above were 
instances of success, I have, in compliance with the opinions of some 
friends, whose opinions I respect, given the cases alluded to as fully 
as I could, and have followed them with some observations upon the 



518 



SECTION OF THE PUBES. 



operation, which should be known to those who might be seduced to 
perform the section of the pubes from the success which followed it 
in Dr. Manchini's hands. 

1689. Dr. Manchini, professor of anatomy at Naples,, has lately 
(1824,) performed the section of the pubes in two instances, and, as 
as he says, with success. In both of these cases it was declared, in 
consultation, that "the delivery could not be effected by the natural 
process. In both instances the children were born alive, and did 
well, and the mothers recovered. After the operation, which consisted 
in a simple division of the symphysis, the patients were put into a 
warm bath, and the farther separation of the bones and dilatation of 
the passages left to the efforts of nature." The reporter says, " I do 
not know exactly what time was necessary for this purpose, in the first 
instance ; but, in the second, the delivery was accomplished in eight 
hours after the operation, when the divided bones were found to have 
separated an inch and a half from each other. The parietal bones of 
the child's head overlapped each other very much, and the whole 
cranium was brought into the form of a cone, from the pressure it had 
sustained in effecting a passage through the openings, which were still 
narrow." 

1690. In the first case, no reunion of the divided parts took place, 
owing to their not having been brought into apposition after the deli- 
very ; from which circumstance the power of walking has not been 
recovered, but is performed in a straddling manner. In the second 
case, the parts were brought together after the accouchment, and re- 
tained in their natural situation by means of rollers properly applied ; 
the bones united, and no inconvenience of any kind, was afterwards 
experienced."* 

1691. I have thought proper to record these cases, as they have 
been received with much complacency by a number of the profession, 
and considered as confirming the opinion of the safety and propriety 
of this operation, as promulgated by Sigault and others, when it first 
came into vogue. At that period it was considered as a real and 
important improvement of the mechanical means of terminating such 
labours as appeared to offer no alternative, but the Csesarean operation. 
Baudelocque attacked these opinions with great force of argument, 
derived principally from well-directed and convincing experiments 
upon the dead and living subject. 

1692. The idea of this operation was first suggested by a passage 
in the works of Severin Pineau, to M. Sigault, while a student of 
medicine, in 1768, and was first performed by himself in 1777, with 
success. 

1693. It was originally intended to supersede the Caesarean opera- 
tion in such cases as were thought could only be terminated by that 
method. But its partisans soon employed it in cases where patience 
or a well-directed choice of other means might have succeeded ; and 

* Anderson's Quarterly Journal, Vol, 1. No. 1, p. 149. 



SECTION OF THE PUBES. 519 

consequently, it was often unnecessarily, if not wantonly performed; 
for we are informed, that it was had recourse to more frequently in the 
period of four or five years, than the Caesarean operation in twenty, or 
thirty, or even in half a century. In a word, Baudelocque says, " that 
the whole art of Midwifery was reduced, so long as the delirium con- 
tinued, to a dexterity in performing this operation ; its partisans ven- 
tured to publish that the operation itself was a trifle ; and that every 
thing depended upon the subsequent treatment." 

1694. It was, however, very early shown, especially by Baude- 
locque, that the original suggestion of this operation byM. Sigault, as 
a substitute for the Cesarean section, was founded in error ; for the 
latter operation is only proposed, where it is physically impossible, 
that a child at full time can be born alive ; or to reduce it to greater 
precision where there is less than two inches and three-quarters in 
the antero-posterior diameter of the superior strait. Now, as there 
are constantly deviations from the measurement just named, to that 
of a few lines, it must follow that there must be gained an increase of 
diameter, equal to the space admitted above, that the operation shall 
be successful. This being granted, (for it cannot be disputed that M. 
Sigault proposed his operation as a means to save the life of both 
mother and child,) it only remained for the opposers of his plan, to 
show, first, the greatest possible increase of diameter that can be 
obtained by the separation of the ossa pubis; and, secondly, the least 
possible diameter to which the head can be reduced with safety. 

1695. It was accordingly shown by Baudelocque and others that 
the greatest possible gain by this operation in the antero-posterior 
diameter of the upper strait, on the dead subject, is from five to six 
lines French, or about half an inch English ; and, consequently, in- 
sufficient in many instances for the object for which it was instituted; 
namely, to preserve the lives of both mother and child. It was also 
shown, that the transverse diameter of the child's head would not 
bear with impunity a reduction below three inches, or a very few lines 
less than its natural diameter ; and of course, that this operation 
would fail, when the antero-postetior diameter could not be increased 
to at least three inches. For it is well ascertained, that the ordinary 
diameter of the child's head from one parietal protuberance to the 
other, is rarely less than three inches and a half, in a full grown 
fcetus. 

1696. These powerful objections were early urged against this 
operation ; and without taking into calculation at that time the mis- 
chiefs that might accompany it, as these were to be tested by farther 
experience. A short period, however, served to prove, that almost 
every operation had a victim, as the life of the child was rarely pre- 
served, and the mother very often fell a sacrifice. 

1697. Frequent opportunities presented themselves in the Hotel 
Dieu of Paris, in consequence of the prevalence of a very fatal epide- 
mic, to ascertain with every necessary precision on the dead subject, 
the space that could be gained by the division of the pubes. The 



520 SECTION OF THE PUBES. 

following is Baudelocque's account of the experiments made by himself 
and others at that time. 

1698. " The subject being placed upon a table, the thighs mo- 
derately separated by two assistants, the ossa pubis receded from each 
other, from three to six lines, the instant the section was made. It 
was not without carrying the thighs forcibly outwards so as to make 
them in several of the women describe right angles with the trunk, or 
the form of the letter T, that we could obtain a separation of two 
inches and a half; and even then we were obliged to pull the hips in 
the same direction as the inferior extremities. That separation was 
not obtained in any one instance without tearing the sacro-iliac sym- 
physes, and that tearing, which began sooner or later, was more or 
less considerable, according to the particular form of the pelvis on 
which we operated, and as the symphyses themselves were more or 
less supple. 

1699. " In a pelvis whose superior strait had but three inches and 
a quarter in the small diameter, and five inches transversely, the 
ossa pubis were scarcely separated an inch, before one of the sacro- 
iliac symphyses appeared open a line and a half, and the other only 
a line. The separation of the former augmented to five lines, and 
that of the latter to three and a half; the periosteum detached itself 
from the bones to a considerable distance, and their anterior liga- 
ments were torn long before the ossa pubis were separated two 
inches and a half. In another experiment on a pelvis of four inches 
seven lines in the small diameter, and four inches and three-quarters 
in the other direction, the ossa pubis could not be separated twenty- 
one lines without detaching the periosteum from the sacro-iliac 
symphyses, and tearing it an inch before them. The symphyses 
themselves were opened so far as to admit the end of the finger, 
and in the sequel separated so as to receive the end of the thumb 
with ease. 

1700. " The external wound, which was two inches and a half, 
was torn in all these cases, as well at the superior as at the inferior 
angle; and sometimes to the extent of several fingers' breadth." 

1701. The experiments of Ripping, Serin, Chevreal, Desgranges, 
Siebold, &c, were generally in strict conformity to those of Bau- 
delocque and his friends, and tended very much to support them. 
The combined results of these trials, prove undeniably, that the 
small diameter of the superior strait cannot be increased beyond 
four or five lines, even when the ossa pubis are separated two 
inches and a half, which cannot destroy the disproportion, as we 
have already said, which exists between the child's head and the 
pelvis in the cases for which this operation was originally proposed, 
if even this degree of separation could with safety be obtained on 
the living woman. 

1702. Besides, Baudelocque very justly calls in question the 
necessity of this operation in some of the cases in which this opera- 
tion was said to triumph, by rendering it very much more than 



SECTION OF THE PUBES. 521 

probable, that the openings of the superior straits, were considerably 
greater than those ascribed to them ; consequently, the degree of 
enlargement procured by the section of the pubes was exaggerated. 
And this was confirmed, in a number of instances, by the woman 
who suffered the operation being delivered previously or subse- 
quently, without adventitious aid. 

1703. Though the section of the pubes purports to be a safer and 
an easier operation than the Cesarean, it is not found to be so, in 
general. That it has been occasionally successful as regards the 
mother and child, must not be denied : but it would seem, in all 
these instances, to have been performed when this operation was not 
absolutely necessary ; or when the milder and safer operation of pre- 
mature delivery would have been the better mode of treating such 
cases. Even after an increase of diameter is procured by the section 
of the symphysis pubis, there is no security, that much after- difficulty 
will not present itself; for the delivery has been afterwards effected 
by forceps and other means, without entire safety to the child ; for 
in most instances, it was either still-born, or died very soon after its 
delivery. 

1704. But were it admitted, that the necessary room can be pro- 
cured when all the parts concerned are favourably disposed, it is very 
far from certain, that this will obtain in the majority of cases. For 
it has been found absolutely necessary to use the saw for the separa- 
tion of the symphyses owing to its unnatural consolidation ; and it 
has occurred that, when the division has been made, that a separation 
of the extremities of the divided bones could not be procured, in con- 
sequence of the ossification of the sacro-iliac symphyses. Now, we 
are informed, that this condition of these parts is not very rare ; but 
it cannot be known, until after the operation has rendered such 
knowledge useless. 

1705. This operation, as a general rule, is very far from being safe 
to the child ; for out of thirty-three operations, but thirteen were 
saved : all the others died, either before the operation, or during the 
extraction ; and it must be remarked that the children which were 
preserved, belonged to women whose pelves were the least deformed ; 
consequently, this operation cannot, as regards the child at least, be 
considered as a substitute for the Caesarean section. 

1706. The evils of this operation, however, are not confined to the 
child ; the mother also is often a severe sufferer ; for when the de- 
formity is extreme, she is sure to die. Of the thirty-three cases just 
noticed, twelve evidently died of the consequences of the operation ; 
and of those who survived, the greater number had been delivered 
naturally before, or safely delivered since ; while several always re- 
mained infirm. 

1707. Beside the grave evils just enumerated, there are many of 
a minor kind, which are every way worthy of consideration, since 
they but too often have entailed misery upon the unfortunate females 
who were the subjects of the operation. Among these may be men- 

45 



522 SECTION OF THE PUBES. 

tioned all the inconveniences which must follow the separation of the 
cartilages from the ossa pubis, and the iliac junctions;* irremediable 
sloughings from the neck of the uterus, and the external parts ; col- 
lections of pus, or sanies in the cellular tissue of the pelvis ; hernia 
of the bladder between the ossa pubis ; extravasations in the psoae 
muscles; injury to the urethra; incontinence of urine; gangrene, 
&c. 

1708. We may also with much propriety notice the evil which fol- 
lowed one of the cases, which gave rise to the present observations ; 
namely, the incapacity to walk firmly. And though it is expressly 
stated this arose from neglect, it is nevertheless one of the penalties 
of this operation, for we hardly dare admit that an operation of such 
moment could have been conducted with such reprehensible careless- 
ness. 

1709. From what we have said upon this subject of the section of 
the symphysis, we may safely draw the following important conclu- 
sions : — 

1710. First. That it can never be a substitute for the Ceesarean ope- 
ration, except the pelvis to be operated upon, has two inches and 
three-quarters in the antero-posterior diameter ; and even when it 
possesses this capacity, it is certainly more dangerous both to mother 
and child, than premature delivery, when the choice is at command. 

1711. Secondly. That this operation is almost necessarily fatal to 
the child, where the deviation is very little below what we have just 
stated it should be, to render this operation even probably safe. 

1712. Thirdly. That in every instance in which the ossa pubis have 
been separated two inches and a half, it has proved fatal to the wo- 
man, and not always safe to the child. 

1713. Fourthly. That it has not been always safe where the 
antero-posterior diameter has had two inches and a half, nor always 
successful when the opening has been more ample, or in other words 
even where it should not have been performed, because it was not 
indicated. 

1714. Fifthly. When more than five or six lines have procured in 
the little diameter of the upper strait, it has always been upon the 
dead subject, and always at the expense of the unions of the ilia with 
the sacrum ; and would consequently be fatal to the living subject ; for 
more than two or three lines cannot be procured in this direction with- 
out serious inconvenience. 

1715. Sixthly. That this operation should never be performed, 
when advantage can be taken of delivering at the seventh month, in 
a pelvis, whose diameter at the superior strait shall have two inches 
and a half, or upw T ards. 

1716. Baudelocque concludes his inimitable analysis, by saying, 
il the section of the pubes cannot at present, maintain any comparison 
with the Csesarean operation ; at most, it might be substituted for the 

* See Chapter on Separation of the Bones of the Pelvis. 



REGIMEN. 523 

forceps, in some particular cases only ; for it cannot, without great 
inconvenience, give an increase of more than two lines from the pubes 
to the sacrum, superiorly ; and that instrument may, without danger, 
reduce the diameter of the child's head that much. But what prac- 
titioner would prefer a new operation, which seems to be surrounded 
by rocks on every side, to one that has been crowned with a thousand 
successes ? If we allow the former any advantages, they would never 
be more evident than in that species of locked head mentioned by 
Roederer, where we cannot, says he, introduce any instrument be- 
tween the head and the pelvis, at whatever part it may be attempted ; 
in this case it would merit a preference over opening the cranium, 
the use of the crotchets and the Cesarean section, as proposed by the 
same author ; it would be preferable, also, where the inferior strait is 
contracted transversely, provided a small separation were sufficient to 
give that diameter the necessary extent." 

1717. The doctrines here taught, are in strict conformity with 
those inculcated throughout the work of this very able accoucheur; 
but they will nevertheless fail to be guides to very many of the 
profession ; this diversity will arise from several causes. First, to 
the estimate which will necessarily be made of the value of the child's 
life, and the risk the mother would run from the section of the pubes. 
Secondly, to the capacity the practitioner may possess of performing 
the operation. Thirdly, to the influence of public opinion. Fourthly, 
to the force of education. 

1718. In the cases which have given rise to these observations. 
Dr. Machini pursued a novel plan after the operation ; namely, 
placing his patients in the warm bath. We are not prepared to say 
how far this step may have contributed to the success of the enter- 
prise ; though disposed at first sight to believe it may be a great im- 
provement, in cases where the acquired room has been sufficient to 
permit the child's head to pass without additional force, and where 
the pains continue with force and tolerable regularity. We would 
think it might be useful, in such cases, to administer the ergot, where 
the contractile force of the uterus is found to flag, rather than to call 
in the use of the forceps, or other foreign aid. For one of the causes 
above related is instructive ; it teaches us that the child may be 
born alive, by waiting patiently a few hours. Had these cases come 
to us more in detail, they might perhaps have been more instructive . 



Sect. VIII. — g. Regimen. 

1719. It was long taught, that the child was entirely dependent 
upon the mother for its nourishment while in utero ; and that for the 
increase of the body, it was constantly necessary to have a supply o 1 
it ; that this increase of the body was in proportion to this supply ; 
and consequently, the ingesta of the mother must have a decide £ 
control upon the size of the child — hence, a woman with a deforme r. 



524 REGIMEN. 

pelvis, has been advised to live very abstemiously with a view to 
diminish the size of the child. This speculation was both natural 
and ingenious ; and there is perhaps but one argument against it ; 
namely, that experience has not proved it to be well-founded. This 
scheme, therefore, is now, entirely, I believe, abandoned. Dr. Hol- 
combe, however, has lately revived it in a letter to the author, where 
he has related several instances of success from a* combination of 
diet and medicines, in considerable deformities of pelvis ; and as 
every thing which has a tendency to preserve life, to dimish danger, 
or to alleviate the sufferings of child-bearing, must be highly interest- 
ing, I trust we shall be doing an acceptable office, in transferring the 
Doctor's observations on this important subject to our pages, in his 
own words. 

" Regimen is another subject but briefly noticed in your work. 
In the short chapter which you devote to it, you merely observe, 
experience has proved, that lessening the quantity of food — on the 
part of the mother, has no influence upon the size of the child — or 
words to this effect. My attention has been turned, for some years 
past, with much interest to this subject; and I have been led to 
believe, from the result of several cases, that, by means of a medi- 
cinal regimen, the size of the foetus in utero may be very sensi- 
bly lessened without jeoparding its safety, or seriously impairing 
the health of the mother: so much so, that a child which would 
otherwise weigh at birth ten pounds, may be made to weigh five 
pounds! My opinion is founded upon the following facts: in June, 
1817, I delivered with the crotchet, (the forceps and ergot had 
failed,) after a fearful labour of sixty hours, a lady with her first 
child. She w r as thirty-two years of age, and had a pelvis more de- 
formed than any I have ever met with. In fact, it is the only pelvis 
actually deformed, which, in a practice of sixteen years, I have had 
to contend with. This lady soon conceived again. Her child, 
however, perished about the seventh month, but was not expelled 
until the eighth; and then, notwithstanding it was in a state of pu- 
trefaction, the labour was protracted, severe, and difficult. I ought 
to mention here that the first child weighed ten pounds and a half, and 
the second, had it lived, would to all appearance have attained the 

same size. Mrs. soon found herself pregnant again, but almost 

immediately afterwards began to complain of symptoms of general 
dropsy, w T hich required for their suppression the daily use of medi- 
cines during the whole period of gestation — particularly a pill com- 
posed of calomel, squills, and digitalis. The calomel kept her 
system almost entirely under the mercurial influence ; and the squills 
and digitalis assisted in nauseating her stomach from day to day. 
At the close of a full period, she was delivered of a healthy child, 
weighing four pounds and a half, after a very sharp labour of five 
hours ! The remarkable difference between this child, and the first 
two struck me forcibly; and I was disposed to account for it, by 
referring it, in a great measure, to the medicinal treatment to which 



REGIMEN. 525 

the mother had been subjected ; and I was determined to test the 
accuracy of the conjecture, by direct experiment, as soon as a 
proper case should come within my control. One soon occurred. 
A pregnant woman, who had never borne a living child, but lost 
three, two of them by instrumental delivery, was easily prevailed 
upon to submit to a course of medicines, by the prospect held out 
to her of an easy labour and a living child, she commenced her 
course about the fourth month of gestation, and continued it very 
perseveringly until delivery, which was effected without difficulty. 
The child (which was alive and healthy,) I did not see, being absent 
from the neighbourhood, but was assured that it was rather smaller 
than children usually are, weighing perhaps about five and a half 
or six pounds. Her other children had weighed from ten to twelve 
pounds. One of them I saw and weighed myself. It rather ex- 
ceeded eleven pounds. The effect of treatment, in this case, I 
considered decisive, and I was confirmed in this opinion by this 
woman's next child, which weighed eleven pounds, and was ex- 
pelled by means of ergot, after a most painful and difficult labour 
of forty hours. The woman had refused, during gestation to submit 
to treatment, or rather her husband, having been ridiculed by his 
associates on account of his dwarf — a plump, healthy little thing, 
by the way, as any in the neighbourhood, had compelled her to 
refuse. Since this case, several other women have submitted to 
medicinal regimen, and the result has been uniformly the same: the 
child in every case being considerably reduced in size, but born alive, 
and to all appearances, with unimpaired health and constitution. 
Thus, sir, have five women, (four of which had never borne a 
living child,) been delivered of living children, with comparative 
ease by means of a medicinal regimen. In four of the cases the 
women had lost (whether necessarily or not, I cannot say,) by the 
crotchet and other means, eleven children. In the fifth case, the 
labour preceding the one which I have noticed was frightfully 
severe, in consequence of the extraordinary weight of the child — 
fourteen pounds! Delivery was effected with great difficulty by 
embryotomy. In the next labour, (the one treated,) the child 
weighed but four pounds! and although a breech presentation, was 
expelled in a few pains. I intend to put this question at rest, if op- 
portunities offer, by farther experiments. Permit me, however, to 
entertain in the mean time, with great confidence, the following 
opinion: that women with faulty pelves, may be enabled, by means 
of a rigid course of medicinal regimen, to bear children alive, who 
could not by any other known method. 

" To illustrate more fully my practice, I will detail to you the treat- 
ment of a single case. 

" June 1st, 1819. — Mrs. , aged twenty-four years, is pregnant 

with her fourth child — has lost three children — owing, I was told, to 
their uncommon size and her contracted pelvis — is supposed to be 
about four months advanced in gestation — is willing to submit to any 

45' 



526 



REGIMEN. 



kind of treatment, however severe, to procure an easy labour, and be 
the mother of a living child. Let her take a pill of the following 
prescription, morning, noon, and night — take also, twice a week, 
forty drops of laudanum, and be bled every month. 

" R. Squills, 48grs.— Calomel, I8grs.— digtalis, 6grs.— Make 
twenty-four pills. 

" August 1st. — Has taken the pills, with a few short intermissions, 
very regularly — mouth slightly sore — appetite impaired— feels feeble 
and dejected, but is willing to persevere in the treatment. Has taken 
the laudanum and been bled twice. 

" Let her take three grains of squills, night and morning — lauda- 
num three times a week, and continue the bleeding. As soon as the 
mouth is well, resume the calomel and digitalis. 

" October 1st. — Resume the calomel and digitalis. August 10th 
— and has continued the calomel, with short intervals of omission, 
constantly since — has omitted the digitalis every other week. Con- 
tinue the treatment ; increasing the squills, as far as the stomach will 
bear — omit the digitalis. Take fifty drops of laudanum every other 
day. 

" November 17th. — Delivered yesterday, after a labour of six 
hours, of a plump, healthy looking child, weighing five and a half 
pounds. Her other children had averaged ten pounds ! 

" Had I the management of a case of more than usual deformity 
of pelvis, I would commence the treatment as soon as conception 
was fully ascertained, and put the patient under a full course of vari- 
ous medicines, particularly of opiates and mercurials, which I would 
urge throughout gestation, as far as a prudent regard for the mother 
and child .w T ould permit. 

" It would be very gratifying to me, if you would give the regi- 
men which I have suggested, a fair trial in your practice, whenever 
a proper case shall offer. Cases of deformed pelvis are seldom 
found in the country. Our resort to the use of the crotchet is con- 
stantly owing to the increased size of the child, rather than a want 
of capacity in the pelvis. 

" The principle upon which my practice is founded, is briefly this ; 
to derange digestion, and keep the liver, that great laboratory of nu- 
trition, iii a constant state of morbid excitement. In conformation 
of my theory, I have collected a number of cases of very small 
children, following bilious and other fevers in which much medicine, 
particularly mercury, had been used. You have frequently noticed, 
I presume, the same fact. Habitual opium-takers also bear small 
children. There is a remarkable case of this kind, at this moment 
travelling the round of the newspapers, copied from some of the 
British Journals."* 

1720. The whole that Dr. Holcombe has urged upon the efficacy 
of regimen and medicine to diminish the size of the foetus in utero, 

* See his letter in the Phil. Jour. Med. Science?, Vol. II. New Series, p. 322. 



MONSTROSITY AND ACCIDENTAL DEFORMITY. 527 

is well deserving attention, especially in Europe, where the necessity 
is much more frequent, as well as much greater than in this country. 
The combination of medicine and regimen may overcome difficulties 
that would not yield to either alone. Yet I cannot but feel strong 
doubts of the united powers in all cases under consideration. Cer- 
tain it is, I have seen strong and robust children born from consump- 
tive parents, and this even in the last stages of it, where the emacia- 
tion was great and the debility extreme. I never met with but one 
decided exception to this ; and this was in the case related in my 
"Essay upon Retroversion of the Uterus ;" and certain it is, I have 
seen healthy and large children from mothers who had been profusely 
salivated ; yet the union of abstemiousness with purging and saliva- 
tion, may effect the desirable reduction of the foetus. 



CHAPTER XLI. 



II. III. MONSTROSITY AND ACCIDENTAL DEFORMITY. 

1721. Both of these may render it necessary to mutilate the child, 
even if a well form ed-pel vis ; for they may produce a relative nar- 
rowness of this cavity. No certain rules can be laid down for the 
former, since their peculiarity cannot be ascertained beforehand. 
Much must, then, be left to the good sense and discretion of the 
practitioner. One thing, however, is certain ; monsters can only 
interfere with labour from an excess of parts. Should the pelvis then 
be faulty, it may subject the woman to all the penalties of a positive- 
ly deformed pelvis. The accidental deformity can rarely cause a 
more serious evil than delay in a well-formed pelvis, though it may, 
in a narrow one create all the embarrassments of a too narrow cavity. 
When the head or abdomen are dropsical in a well-formed pelvis, 
perforating them will almost always relieve the woman by the evacu- 
ation of the water ; but in a narrow pelvis this is not sufficient ; since, 
by that operation only, the excess of size is removed. I once saw 
rupture of the uterus from a hydrocephalic head. See " Essay on 
Rupture of the Uterus," by the author. 



528 UNCERTAINTY OF THE CHILD'S DEATH, 



CHAPTER XLII. 



1722. In many instances it would be highly important, could we 
determine with certainty, that the child was dead while in utero, it 
would serve to abridge the sufferings of the mother, and sometimes 
would spare the accoucheur a deep-drawn sigh ; but this is a matter 
of great difficulty, as well as oftentimes of great moment to decide. 
All the commonly enumerated signs have been known to fail, and 
even when many of the strongest were united ; of this, Baudelocque 
(System, par. 1898.) gives us a most memorable and interesting ex- 
ample — an example that should be well studied, and carefully trea- 
sured against the time of need. 

1723. The too implicit reliance upon certain of the signs which 
are said to characterize the loss of life in the child, has been the 
cause of the immolation of thousands ; and we cannot too earnestly 
deprecate this facility of credence, when we have but too much rea- 
son to wish it were so. There are but two unequivocal signs of the 
child's death ; namely, a cessation of pulsation in the umbilical cord 
when prolapsed ;* and the scalp forming a soft tumor in which the 
bones of the cranium can be felt loose and detached ; resembling 
much in feel, the distended membranes. 

1724. The escape of offensive gas ; a separation of the cuticle or 
hair ; a rolling motion within the abdomen ; a shrinking of the abdo- 
men ; and the cadaverous appearance of the woman — are but uncer- 
tain signs of the child's death. Velpeau says, among other signs, 
" the death of the child is declared during labour, by the escape of 
the meconium." We sincerely hope that the young practitioner may 
never take this for the sign of the child's death ; as this appearance 
every now and then takes place, when the child is in the most per- 
fect health. We have known it to happen at least twice, in presen- 
tations of the head, and pretty frequently when the breech has been 
the presenting part. For the meconium to escape from the rectum, 
it appears only necessary that the child's abdomen should be pretty 
strongly compressed. 

* Agreeably to Dr. Blundell, this mark is not rigidly a proof of the child's death. 
He desires us to " remember, that where the cord comes down, a temporary suspension 
of the pulsation for a few minutes, may airse from syncope."— Prin. and Prac. of Ob-, 
stet. p. 533. This, however, we have never met with : it may, however,, be a salutary 
caution. 



ON THE SECALE CORNUTUM, OR ERGOT. 529 



CHAPTER XLIII. 



ON THE SECALE CORNUTUM, OR ERGOT.* 

17-25. I have often had occasion to mention this substance as a 
powerful auxiliary in the practice of midwifery, and as it has obtained 
throughout this country as well as in Europe, a high reputation, it may 
be well to inquire into its pretensions. I am more anxious to do this, 
as the claims of the ergot have been extravagantly urged in some in- 
stances, while in others, the employment of it has been as seriously 
deprecated ; nay, it has been condemned in a few instances as useless, 
and even hurtful. 

1726. The action of this substance appears to be specifically upon 
the uterine fibres ; urging them sooner or later to more or less violent 
contraction. It is not the alternate contraction alone that is in- 
creased by this substance ; the tonic is also powerfully augmented, 
which is of much more value, since it can, in consequence of this 
power, be most advantageously employed in many cases where this 
effect would be all-important. In this respect its effects appear to 
be very different from every other stimulant which has an influence 
upon this organ, such as opium, the oil of cinnamon, volatile alkali, 
&c, or the mechanical stimulus of the forceps, vectis, or the 
hand.f 

* It is more than probable that the powers of this substance over the uterine fibre 
was known in Germany long- before it attracted notice in either France, or in this 
country. The German name for this substance, according to Goupil, is illustrative of 
such knowledge ; the ergot is called " mutter korn," or womb grain, mutter signifying 
wonab. This conjecture is strengthened by a fact mentioned 10 me by Dr. Lorain of 
Philipsburgh, Pennsylvania. He says he was called to the assistance of a very old 
self-created midwife, then many years from Germany. He found that she had given 
large doses of the infusion of the sccale cornutum before his arrival, the use of which 
she declared she had learned previously to leaving her own country. The insu- 
lated situation of this woman's place of residence ; her almost entire ignorance of the 
English language; her 1 ng residence in the neighbourhood in which she was found ; 
the little communication she could have with enlightened society ; and the little dis- 
position she manifested to L'ain information in her profession, render it next to cer- 
tain, th'jt she had beome acquainted wi'h the properties (f the ergot before she left 
Germany, as she has declared ; a period long antecedent to our knowledge of it in this 
country, and perhaps, as early as it was known in France. 

t I hi ve never wHnessed any exaltation of the powe-s of the arte ial pys'em,or any 
other marked effect, (if we except i's s ecific action, 1 } from the exhibition of the ergot 
though T hive been very atteniive <o the subject. But it is declared by Dr. Oslere, on 
the authority of Dr. Erskine and others that it slightly increases the fulness and fre- 
quency of the pulse, produces a glow over the surficc; excites Da use*, and sometimes 
vomiiinjr; P'in and jjiddiness of the head. — Philadelphia Journal of the Medical and 
Physical Sciences, So. III. New Series. 

As far as I have been able to determine, the effects of this substance are confined 
to the nervous system; and through its in'crvcntion acts specifically upon the uterus. 



530 



OF THE SECALE CORNUTTJM, OR ERGOT. 



1727. Each of the stimulants just mentioned has been known to 
rouse the alternate contractions of the uterus into a temporary and 
sometimes successful action ; but after neither, does the tonic contrac- 
tion follow, with any marked degree of certainty, nay, we may with 
much truth declare, that the inertia of this organ is very apt to follow 
their employment. Thus, we witness hemorrhage sometimes follow 
the use of either of the remedies just named, though they may have 
been successfully exerted, as regards the mere delivery. But, so 
far as my own experience goes, or a pretty extensive inquiry will 
justify the declaration, I can say, lhat neither myself nor such of my 
friends of whom I have asked the question, have ever witnessed such 
a consequence follow the use of the ergot. 

1728. So far then, I think, we may with much confidence declare, 
that every other stimulus which has contributed to the energy of the 
uterus, except the ergot, has been followed occasionally by inertia of 
this organ : this fact is of high practical importance, as it leads us to 
an almost certain mode of treating such females, as may be habitually 
liable to floodings after delivery. It also, on the other hand, points 
out a caution of equal practical usefulness ; namely, not to exhibit it, 
when there may be a chance that turning may be necessary ; but 
more of this presently. 

1729. There is another peculiarity attending the action of this sub- 
stance, not less remarkable, perhaps, though not equally important 
as those just noticed ; namely, the promptitude of its action ; for we 
have constantly observed, that if it do not manifest an influence in 
twenty minutes, or half an hour at farthest, it utterly fails. The ac- 
tion of this .substance is generally so extremely prompt, as sometimes 
to create a doubt of its agency in the minds of those unaccustomed 
to its operation. But I am every way certain, that the " ergot " 
never acts with so much efficacy, as when it acts quickly; indeed, I 
might say, that its success is almost in proportion to its prompti- 
tude.* By many, this very sudden action of the uterus has been at- 
tributed to coincidence, rather than to the effect of this remedy. 
This occasionally is certainly the case ; as we see changes, similar to 
those effected by the " ergot," take place as suddenly where none 
has been exhibited ; but it would be unfair to declare this to be the 
case always. 

1730. Thus, on the 11th November, 1827, I was called to Mrs. 
V. in labour with her fifth child ; the waters had discharged them- 
selves half an hour before my arrival, and the patient had expe- 
rienced a number of very smart pains. After the escape of the liquor 
amnii, the pains abated in force and frequency. On the accession of 
a pain, I examined my patient, and found the presentation to be a 

Nor are its powers confined to the human uterus ; it acts with equal and similar effi- 
cacy upon the u'erus of the brute. We are told, it is familiarly used near Lyons to 
aid the parturient cow. 

* Goupil says, " la rapidite avec laquelle le ' seigle a produit son effect es relement 
suprenante ; elle peut etre comparee h Taction de l'&metique." 



OR THE SECALE CORNUTUM, OR ERGOT. 531 

first presentation, and the head arrived at the inferior strait; the 
mouth of the uterus was fully dilated, and every thing gave promise 
of a speedy delivery. But the pains became still more feeble, and 
longer apart ; and after waiting an hour and a half for their amend- 
ment without advantage, I resolved upon exhibiting the ergot ; es- 
pecially as my patient became clamorous for its exhibition. The 
ergot was accordingly sent for ; the messenger had scarcely left the 
house, before the powers of the uterus were spontaneously roused, 
and with such efficacy, that the child was upon the point of being 
born when it arrived ; it was, therefore, not given ; ten minutes more, 
were all that was necessary for the completion of the delivery. In 
this case, had the ergot been given, the alteration in the action of the 
uterus would doubtless have been attributed to it, by those unac- 
quainted with the peculiarities of its action ; yet an experienced eye 
and ear would readily have detected its want of efficacy, did it exert 
no power, as well as be able to determine its agency, if it had really 
weakened the powers of the uterus. 

1731. As regards myself, I have the most firm reliance upon the 
powers of the "ergot;" and the character of its action is so distinctly 
marked, that a very little observation will lead us to detect it. 
Whether the peculiarity of the effort produced by the ergot has been 
observed by others, I cannot say;* it appears, however, to be per- 
fectly well defined and highly characteristic ; and I think, I am al- 
ways able to distinguish the cases of coincidence, from those in 
which the ergot was decidedly operating. 

1732. When ergot has been successfully administered, we find the 
uterine effort not only more quickly repeated, and more powerfully 
exerted, but these efforts are accompanied with less suffering than the 
same apparent exertions of this organ, when it is not urged to action 
by this drug. The woman, when interrogated with respect to her 
feelings, expresses her sensations by saying, she feels " as if every 
thing was forcing from her;" but at the same time admits, that the 
pains have not the same character with those she suffered before ; in- 
deed, it very frequently happens that there is a great abatement of 
suffering, by converting a concentrated pain, and this most frequently 
in the back, to a more generally diffused one over the abdomen; or 
by obliging the back to participate, if the abdomen has been the parti- 
cular seat of it. At the same time it must be confessed, that the in- 
tervals between the contractions are more uncomfortable, as an almost 
constant nisus is kept up by the excited, or, as it would seem, the 
goaded uterus, though the sensation does not amount to pain. Now, 
the presence of the circumstances just noticed, constitutes the peculi- 
arity of the action of the secale cornutum. 

1733. Some of my medical friends, but they are very few indeed, 

* Many speak of its specific action, or of its specific influence ; but I do not recollect 
to have seen any account of the details, in which these specific effects consist. 



532 ON THE SECALE CORNUTUM, OR ERGOT. 

declare they have never witnessed any effect whatever from tlie ergot, 
even when it has been administered in large doses.* I account for this 
discrepancy in result, only by supposing the ergot which they em- 
ployed was effete ; a circumstance, [ have reason to believe from ex- 
perience, of no unusual occurrence. 

1734. The like want of faith in the powers of this article, seems to 
prevail with many respectable practitioners in Europe, and which may 
be accounted for, perhaps, upon the same principle. Dr. Davis, an 
accoucheur of deserved eminence, says, that "the pretensions of the 
secale cornutum have been generally known to the profession for 
nearly twenty years ; yet the actual fact of its power has not been 
satisfactorily established ; nor is there evidence of its having in a single 
instance, superseded the necessity of using the forceps."! This as- 
sertion, it must be observed, is one which admits of no possible de- 
monstration ; since it would be impossible to prove that the case in 
which the ergot appeared to be successful would absolutely have re- 
quired the use of the forceps, or that the cases relieved by the forceps 
might not in many instances have been successfully treated by the 
ergot ; yet so far I can safely aver, that a number of instances have 
occurred in which I believe I should have employed the forceps, pre- 
viously to my acquaintance with the powers of the ergot ; but which 
w T ere terminated by this drug, both promptly and safely. And farther, 
I am certain, that I do not use the forceps once now, where I used 
them formerly ten times. 

1735. And the reason of this abatement in the employment of the 
forceps, may, I think, be justly attributed to the almost universal use 
of the ergot, by every kind of practitioner of midwifery ; and hence I 
presume, that the secale cornutum now achieves deliveries that would 
have required the forceps formerly ; for were this not the case, I think 
I should be called upon, as formerly, to aid labours with these instru- 
ments. 

1736. As every thing almost depends upon the proper preservation, 
and quality of the ergot, it should be kept whole, in a glass bottle 
with a ground stopper ; and only powdered, pro re nata ; nor should 
we ever use it after it exceeds a year in age, if possible to prevent it. J 

* Chausieur and Madame La Chapelle, declare they have never witnessed any effects 
from the ergot, in the trials they made of it, in •' la Maternite de Paris." 

t Ele. of Oper. Midwifery. 

X We are, however, informed by Lorinsor, (Edinb. Med. and Surg. Journal for Oct 
1 826, p. 453,) that it preserves its powers perfectly for two years, as far as regards its ope. 
ration on the stomachs of men ; but whether it retains its specific powers upon the uterine 
fibre for that period, does not appear to have been ascertained by his experiments. On 
the other hand we are directed by Goupil, (Journal des Progres des Sciences, et Insti- 
tution, &c. vol. iii. 1827, p. 170,) in order to be certain of the peculiar properties of this 
substance, to use it the same year in which it has been collected ; that it must be kept 
in bottles hermetically sealed, and not to be powdered but as it may be wanted. It 
appears from the experiments of M. Bocttcher at Mendelurtz, that the energy of the 
ergot very much depends upon the period at which it is collected before harvest, while 
that procured after harvest is altogether inert. — Amer. Jour, of the Med. Sciences^ Au- 



ON THE SECALE CORNUTUM, OR ERGOT. 533 

For the ergot, like almost every other vegetable substance, is easily 
acted upon by heat and moisture, and consequently is easily deterio- 
rated, when exposed to their influence. I have, in several instances, 
failed to produce the slightest effect with the ergot procured at one 
shop ; whilst that from another, in the same patient, has been as 
prompt as efficacious. 

1737. I have generally administered the ergot in substance ; some 
prefer it in infusion.* Twenty grains in a little sugar and water may 
be given at once ; and I seldom exceed this quantity, as I have 
rarely found the farther exhibition of it attended with better effect. 
My valued friend, the late Dr. George Holcombe, of Allentown, 
New Jersey, objects very strongly to the quantity just named ; and 
proposes much smaller doses, but more frequently repeated ; or as 
often as it may be necessary. But as the whole of Br. Holcombe's 
observations on this subject are of great practical value, I feel I shall 
be doing a general good, as well as performing a duty, to give them 
at length, together with some observations upon them. 

"Allentown, JV. /. Nov. 21, 1825. 
" Dear sir — I have just finished reading your System of Mid- 
wifery, and have to request you to accept my thanks, in common 
with the profession, for the much novel and valuable information 
which it contains. 

gust, 1833. No. xsiv. p. 515. See page 539, par. 1199, for a farther account of the 
action of the ergot. 

Chemical Analysis of Ergot. — In 103 parts of ergot, M. Wiggers, of Berlin, has 
found — 

White oily matter - .--.--. 35.0006 

Solid fatty matter, crystallizable, and of peculiar nature - 1.0456 

Cerine ------------- 0.7578 

Fungous matter -------- i .. - 46.0862 

Ergotine ----- - - 1.2466 

Vegetable ozmazome --- - 7.7645 

Sugar - - 1.5530 

Gummy extract, with red colouring principle - 2.3250 

Vegetable albumen ----------- 1.4800 

Acid phosphate of potash ---------- 4.4221 

Phosphate of lime, and traces of iron - 0.2822 

Silica ...----.-.-- 0.1394 

102.0930 
There are some remarkable points in the preceding analysis. In the first place the 
presence of vegetable ozmazome indentifies the ergot with the class of mushrooms, in 
which this substance forms a considerable proportion. In this ozmazome seems to 
reside the power which promotes parturition. The ergotine is insoluble in water, and 
seems, from the experiments of M. Wiggers, to be the principle in which the poisonous 
qualities of the ergot reside. On several animals it has operated as a powerful irritant 
poison, while the ozmazome produced no such effect. — Lancet, from Alleg. Med. Zeit. 
10 Nov. 1832. 

* Bordot informs us that the old women in the department of "Cote d'or," infuse a 
handful of this substance in a cup of water, and give a table spoonful of it every five 
minutes. This dose, Goupil observes, is much stronger than that pointed out by ac- 
coucheurs ; but he says we must notice the manner in which it is taken, as it is much 
less active than when given in powder. — Ibid. p. 171. 

46 



534 



OR ERGOT, 



" Permit me to call your attention, for a few moments, to several 
subjects which have been but briefly noticed in your work : the first 
is ergot. This extraordinary agent owes its introduction into the 
materia medica entirely to American physicians, and as yours is- 
the first system of Midwifery which has issued from an American 
source, since its use has become general, the profession both here and 
abroad, looked to your pages for a more particular account of the 
properties and uses of ergot than has heretofore been given. I am 
afraid they will be much disappointed, as I frankly declare to you I 
have been, in finding it passed by almost unnoticed. Much, it is true,, 
has already been written concerning it ; and, I am aware, that prac- 
titioners are supposed to be well informed as to its properties, and 
the cautions necessary to be observed in its administration. But this 
I am persuaded is a mistake — and, in my opinion, you could not 
more efficiently subserve the cause of humanity, and obstetrics, than 
by devoting a chapter in the next edition of your work to the consi- 
deration of the uses and abuses of this article. 

" The scruple dose, as a general prescription for aiding the expul- 
sive stage of labour, I am convinced, from considerable experience, 
is exceptionable and dangerous. In ordinary cases, no mischief, it 
is acknowledged, will result from the exhibition of so large a dose. 
But the child, if it be unusually large,, or the pelvis faulty, or if the 
accoucheur have to contend with a first labour, will always be put to 
imminent danger, and frequently destroyed by scruple doses, when 
its safe delivery might have been effected, either by.the unassisted 
energies of the mother, or by small divisions of the dose, frequently 
repeated. 

" Your zeal in proscribing the use of the crotchet, will doubtless 
obtain, as it certainly merits, the plaudits of your brethren — at least 
of the more enlightened portion of them. But if the use of the terri- 
ble instrument just named be as reprehensible, (and who will presume 
to deny it ?) as you have represented it, how much less so, or rather how 
much more so, is the intemperate use of an agent which sacrifices a four- 
fold, if not a twenty-fold greater number of victims ? More children I 
am satisfied from what I have seen and heard, have already perished by 
the injudicious use of ergot, during the few years which have followed 
its introduction into the practice of this country, than have been sa- 
crificed by the unwarrantable use of the crotchet for a century past f 
This, if correct, is a most serious fact ; and of its truth I do not 
entertain the slightest doubt. 

" But notwithstanding the strong language I have just used, I 
regard ergot, when cautiously administered, as a most interesting and 
valuable adjuvant in the practice of midwifery. I have used it con- 
stantly, since Dr. Stearns first called the attention of physicians to it. 
For some time I used the scruple doses, or corresponding doses of the 
decoction, which, I am afraid, are every where yet too common, but 
soon abandoned this practice in consequence of several fatal demon- 



OF THE SECALE CORXUTUM, OR ERGOT. 535 

strations of its impropriety. Since then I have administered it in 
very small doses — say from two to three grains, which I repeat as 
often as may be necessary ; and in this manner, I am generally able 
to effect my object ; and always without injury to the mother or 
child. In fact, I have never know T n a child perish from ergot, admi- 
nistered in this cautious manner. I prescribe it now- unhesitatingly 
in first labours, and even in cases of contracted pelvis ; and such is 
the extraordinary energy imparted to the uterus, by the slow but per- 
severing mode of exhibition which I have adopted, that I have very 
rarely found it necessary, for several seasons past, to resort to the use 
of the forceps. 

u Independently of the power of the ergot in aiding the expulsion 
of the child, it seems to possess other important properties in the prac- 
tice of midwifery. I have never seen a case of peurperal fever fol- 
low its administration. This fact may be accidental, and confined to 
my experience ; but the remark, I have thought, might be interesting 
to you as a teacher of midwifery — at least worth noticing.* It some- 
times completely extinguishes the lochia ; but this effect has never 
resulted, so far as I have observed, in injury to the mother. f I pre- 
scribe it, which I believe is a common practice, w T hen flooding after a 
delivery is apprehended. Also, in cases of partial prolapsus of the 
uterus, and of habitual bearing down, from whatever cause the last 
distressing affection may arise ; and I am much deceived, if great 
comfort is not frequently derived from this precautionary exhibition of 
the medicine, in each of the diseases just specified.}: But I am afraid 
I am extending my observations beyond your time and patience ; I 
will, therefore, close them, by repeating the suggestion which I have 
already taken the liberty to make — that you would confer a great 
benefit upon midwifery, by devoting a chapter in the next edition of 
your work, to the medicinal history of ergot. The profession, I re- 
peat, expect it of you ; and permit me to add, from the situation 

* It would be a most valuable acquisition to our remedial means, did the " ergot" 
contribute to the lessening of the cases of puerperal fever. Upon this point, I can say no- 
thing practically ; it may be true, as stated by Dr. Holcombe, that this may be con- 
fined to his own experience, or rather that it may be merely coincident; yet it deserves 
serious attention ; for this substance may have a prophylactic power. I would therefore, 
earnestly recommend this subject to the attention of the accoucheurs of our country, and 
especially to those who may inhabit districts, in which this too fatal disease sometimes 
becomes epidemic. 

+ " It sometimes completely extinguishes the lochia.* 1 * 1 have never seen this effect 
follow the use of the "ergot." Nor do I believe it generally necessary that it should do 
bo; for if the labour have been well conducted through all its stages, lochia will rarely 
be too abundant. See Chapter on the Lochia. Yet it may be highly important to be 
in possession of a remedy when the diminution of the lochia may be an object. 

t The usefulness of the -'ergot" in the last specified affection, namely, "habitual 
bearing down," is certainly contrary to all reasoning upon the subject; and would be, 
if correct, one of the many instances in which we are obliged to make speculations, 
yield to experience. 

* I pre§ume Dr. H. only means by *' Extinguishing the lochia.*' a great diminution of it. 



536 



ON THE SECALE CORNUTUM, OR ERGOT. 



which you occupy in American obstetrics, has a right to expect it of 
you. But, to return : 

1738. I think I am right, when I say there is no decisive instance 
extant, in which the " ergot" has had a direct unfriendly influence 
upon the child. I am aware much has been said to the contrary by 
many respectable practitioners ; but I think it would be no difficult 
matter to show, that when a still-born child has followed the exhi- 
bition of the " ergot," it has been constantly owing to the following 
circumstances. First. It has been given too early ; that is, long be- 
fore any reasonable expectation should have been entertained that de- 
livery would soon follow its exhibition, owing to the want of relaxa- 
tion in the soft parts. Second. Given when the head has not been 
well situated, and the practitioner, perhaps, not aware of this circum- 
stance ; consequently, making a wrong estimate of the time that 
must elapse before delivery could take place, after its exhibition. 
This error very commonly arises from the facility with which the head 
of the child may generally be felt, or its supposed disposition to 
escape through the external parts, because they, as well as the uterus, 
are favourably disposed. No mistake is more common than this 
among practitioners who are ignorant of the mechanism of labour; 
for they suppose there is but little to do ; and " were the pains but a 
little stronger, the child would soon be delivered." Under this delu- 
sion the ergot is given, with every expectation of a speedy issue. 
But this does not take place agreeably to their hopes, and very much 
to their surprise, for they are altogether unable to account for the fail- 
ure. Whereas, an enlightened practitioner w T ould instantly have de- 
tected the wrong position of the head, and would have seen at once 
how much was yet to be effected before delivery could take place. 
He would also have been able to determine very nearly the time and 
the degree of effort it would have required to terminate the labour ; 
and the ergot would have been withheld until more had been done 
by the unaided contractions of the uterus. But the better to illustrate 
this fruitful source of error, we will first refer to the position of the 
head, when not well situated; and secondly, to the difficulty the head 
sometimes finds in undergoing these changes, even when it is well 
situated; though the soft parts may be favourably disposed. 

1739. 1st. The difficulty arising from the position of the head. 
Thus, in the fourth, fifth, and sixth presentations, there may be much 
delay, from the forehead being sometimes obliged to come under the 
arch of the pubes, as in the fourth, and fifth, probably, if not changed, 
and unavoidably in the sixth ; which circumstance may have escaped 
the calculation of the practitioner at the time he exhibited the ergot ; 
or he may have been ignorant of it ; consequently, much unlooked- 
for delay may ensue, and this sometimes to the injury of the child, 
and the uterine parietes. But in this case, no blame should attach 
to the " ergot" specifically ; for the same consequences will follow 
from the long continued efforts of the uterus, where none of this sub- 
stance has been administered. Baudelocque gives us instances of 



ON THE SECALE CORNUTUM, OR ERGOT. 537 

this kind ; and every practitioner of any standing must have observed 
the same thing ; indeed, the danger of the child after the evacuation 
of the waters, is always in proportion to the tonic power and the con- 
tinuance of the alternate contractions of the uterus ; hence, we have 
always reason to apprehend, that the child will be still-born ; when 
the uterine contractions continue very long, and with much force, after 
the discharge of the liquor amnii ;* we are persuaded this is agreea- 
ble to the experience, of all who practice midwifery. If this be so, 
when no " ergot" has been administered, it may certainly a fortiori 
happen, after it has been given, without any blame being justly 
attached to its powers. Some have carried their apprehensions of 
this substance so far as to declare it will produce vesications, and 
inflict other injuries upon the child's skin, in the short time that shall 
elapse between its exhibition and the final termination of the labour. 
This is even more incomprehensive, and incredible than the influence 
of the imagination upon the foetus in utero ; at least it should be classed 
with it. 

1740. Secondly. The difficulty the head sometimes finds in un- 
dergoing the changes necessary for its escape from the pelvis, when 
the soft parts are well disposed. 

1741. This may arise from several causes. First, when a proper 
relation does not exist between the head and the pelvis, even when 
the head is well situated. When this happens, a long series of efforts 
will be required, to force the posterior fontanelle to place itself under 
the arch of the pubes ; and nothing but an enlarged experience, with 
an entire knowledge of the mechanism of labour, will enable the prac- 
titioner to determine the quantity of force, and the lapse of time that 
will be required for this purpose. In this case, should the " ergot " be 
resorted to, it will be blamed if the child be still-born, when it is 

* It is evident from the nature of the communication betweon the mother and child 
while in utero, that the latter is altogether dependent upon the continuance of circu- 
lation for its life ; that this circulation is maintained by means of the placenta; and, 
consequently, will be more or less perfect, or cease entirely, as this mass may preserve 
its connexion with the uterus unrestrainedly, be embarrassed or have its cells, or ves- 
sels altogether obliterated, by the degree of force exerted by the contracting uterus. 
And that the degree of compression which the placenta may suffer, will be in the di- 
rect ratio of the power of the tonic, and the frequency and force of the alternate con- 
tractions of the uterus : now, the former will be strict almost in proportion to the time 
that elapses after the waters have escaped ; and the latter will be repeated, as often as 
the susceptibility of the uterus will enable it to contract. It will follow, then, that 
whatever increases the tonic and alternate contractions, will increase the circum- 
stances just named as being unfavourable to the security of the child, and which must 
necessarily be augmented in proportion to the delay, which supervenes, from the rup- 
turing of the membranes, to the birth of the child. If, then, the ergot be given after 
the waters are evacuated, and much delay take place in the delivery, the child must 
almost necessarily suffer; not because the ergot has an unfriendly influence directly 
upon it, but because it was given when the uterus had too much resistance to overcome ; 
a delay is thus created, which exposes the placenta to every degree of compression, 
eren to the entire stopping of the circulation within it — when this happens the child 
must die, if not very speedily relieved from its thraldom ; and, hence, we sec children 
still-born, sometimes after the use of ihe ergot. 

46* 



538 ON THE SECALE CONUTUM, OR ERGOT. 

altogether the fault of the practitioner — for in this case, the " ergot " 
should not have been given, so long as the natural pains continued 
powerful ; for it is not so much by multiplying the force, as by repeat- 
ing its application, that the desirable end is effected. We have known 
the " ergot " given under these circumstances, and the uterus to 
become exhausted by being thus unduly urged : and the only re- 
source ultimately has been in the forceps. Secondly, at other times, 
when the posterior fontanelle has even placed itself under the arch of 
the pubes, it will sometimes require the long-continued and the often- 
repeated efforts of the uterus, to carry the parietal protuberances below 
the tubers of the ischia. Now, if " ergot" be given in this case, it 
may be blamed, if the child be still-born, when it had no agency in 
the disaster. 

1742. Dr. Henry Davies says, "It may be observed, that in some 
cases, when the pelvis was a little confined, and when the head was 
not sufficiently low down for the application of the common forceps, 
the secale has been successfully used, and the child delivered with 
the forceps: very great discretion in these cases is required."* Dr. 
Davies gives several w r ell marked instances of the influence of the 
ergot in feeble action of the uterus. 

1743. But certainly the most common cause of the failure of the 
"ergot" is owing to its injudicious and indiscriminate exhibition. 
It has been given, we have well ascertained, before the membranes 
have been ruptured ; the os uteri not at all dilated, and the external 
parts quite rigid. What but defeat and injury can result from such 
an. improper use of this powerful aider of uterine contraction ? This 
substance is now in familiar use among mid wives, who have neither 
principles nor experience to direct its proper employment; and we 
are credibly informed, it is used in this city by a practitioner in ex- 
tensive business, in almost every case to which he is called. 

1744. This is truly the abuse of a valuable remedy ; for if our in- 
formation be correct, the too free use of it in this gentleman's practice, 
has occasioned very many cases of prolapsus uteri. This effect of 
the ergot may perhaps be questioned by some, but I have not the 
smallest doubt of the fact, from what I have seen, when this medicine 
had been improperly taken. A lady aborted at a little beyond the 
fifth month with twins. The involucra did not come away for several 
days after the expulsion of the embryos; and as they came off in one 
mass, very soon after taking twenty-grains of " ergot " in powder, the 
lady could not be persuaded but that one of the placentae remained, 
and became very anxious for its discharge, and desired, that another 
dose of the ergot might be given her — this I absolutely refused ; but 
at the same time assured her, in the most positive terms, that nothing 
remained to come away. It seems, however, that she was not con- 
vinced ; for I had scarcely left the house,, before she caused another 
portion of the ergot to be given her. The consequences were, a re- 

* Med. and Phys. Journal, July and August, 18&5. 



ON THE SECALE CORNUTUM, OR ERGOT. 539 

petition of violent pains, and the escape of a considerable portion of 
the uterus through the os externum. She became now excessively 
alarmed, and I was sent for in haste. I found her in great agony; an 
agony resembling that of the last moments of labour ; and upon exa- 
mination, the uterus was found in the situation just mentioned. 

1745. The uterus, owing to the constant and violent nisus created 
by the ergot,* was restored with some difficulty; and the pains were 
appeased after awhile by large doses of laudanum. She was obliged 
to wear a pessary for a long time, before the uterus recovered its 
position. 

1746. I am therefore, persuaded, that much future injury may be 
sustained, by giving this medicine in cases where there is little or no 
resistance to be overcome ; for in such cases the increased efforts of 
the uterus, produced by the ergot, continue after the child is delivered, 
as its impression does not immediately wear off: this took place in 
this case at a time when the uterus had nothing to support it, or to 
retain it within the pelvis ; it must, therefore, become prolapsed, if 
not protruded. 

1747. From what has been said, it would appear that the ergot is 
a powerful medicine; so powerful, indeed, that well defined rules 
should be laid down for its use. It would seem, that it is the im- 
proper exhibition of this drug, and not a specific power, that creates 
the evils but too commonly charged to it ; also, that there is no satis- 
factory evidence of its exercising any baneful effects upon the child 
in utero. 

174S. The following rules for the use of the ergot, if attended to, 
I think will prevent any evil following its exhibition. 

1749. 1st. It should never be given before the membranes are rup- 
tured, the os uteri dilated, and the external parts disposed to yield. 

1750. 2d. It must not be used, so long as the natural pains are 
efficient, and competent to the end. 

1751. 3d. But should they flag, from any cause, it may be given, 
provided the labour be a natural labour, according to our acceptation 
of the term " natural labour ;" that is, when the head, (if well situated,) 
the breech, the feet, or the knees present. For, independently of 
any accident which may complicate the labour, it is sometimes de- 
sirable, for the safety of the child, to hasten it, when the natural powers 
are incompetent to this end. 

1752. 4th. And if the labour be accompanied by any such accident 
as flooding, convulsions, syncope, &c. (see par. 651) it may some- 
times be employed to great advantage, provided rules 1 and 2 are 
not violated. 

* This effect of the ergot has often been noticed; the impression it makes upon the 
nervous system remains a long time; sometimes even after this substance has been 
rejected from the stomach; in this respect, it is like opium, rnd some other narcotics. 
Desgranges assures us he has seen this : yet the delivery has gone on with equal 
speed and certainty. 



540 ON THE SECALE CORNUTUM, OR ERGOT. 

1753. 5th. It may be used very often with much advantage in 
every kind of premature labour ; and at full time, when the placenta 
is not thrown off, and the uterus is found in a state of atony. 

1754. 6th. Where flooding takes place after the rupture of the 
membranes, the os uteri well dilated, the pains feeble, but the child 
well situated, and the pelvis well conformed. 

1755. 7th. Where the head of the child has been left in the uterus 
by being separated from its body. 

1756. 8th. Where the uterus is painfully distended by coagula. 

1757. Dr. Ward, of New Jersey, recommends, that the ergot should 
be used, " in alarming uterine hemorrhages, which sometimes take 
place before delivery, whether it takes place in consequence of a 
detachment of some portion of the placenta, it being attached to the 
fundus uteri, or whether it be owing to a separation of its attachment 
over the orifice of the uterus." In this advice, I cannot agree with 
this respectable practitioner ; for, in the first instance, he states, there 
can be no advantage derived from exciting, or increasing pain, unless 
the os uteri be well opened, and the membranes protruding, that they 
may be ruptured, if this can be done with propriety ;* for until the 
liquor amnii be expended, the hemorrhage cannot be arrested by ex- 
citing the alternate contraction of the uterus ; and the tonic, by which 
this discharge can alone be stopped, under such circumstances, cannot 
take place, until the membranes have given way. 

1758. In the second case in which Dr. Ward proposes the ergot, 
we apprehend it would be decidedly mischievous ; as it is found, 
that in placental presentations, the flooding is always increased by 
pain ; as it directly tends to augment the separation of the placenta. 

1759. It may, however, be said, that in the unavoidable hemor- 
rhage, an advantage may be derived from the exhibition of the ergot, 
by hastening labour, though it may for a short time increase the dis- 
charge. But in order that this reasoning may have any value as a 
practical precept, the cases in which this advantage could be derived, 
should be extremely well defined ; nothing should be left contingent 
in a complaint so dangerous, and which has but one successful mode 
of treatment, so far as we yet know ; namely, the delivery of the 
child. Now, with these admissions, we are every way disposed to 
receive any evidence in favour of the remedy proposed, and for the 
particular species of hemorrhage in question. And if Dr. Ward will 
assure us from his own experience, that the ergot will supersede the 
necessity of artificial delivery from the promptness with which it ef- 
fects delivery, we wall hail this substance, as one of the most valua- 
ble of our therapeutical remedies ; but until this be done, we shall 

* We say "if the membranes can be ruptured with propriety ;" for this cannot, nor 
should not always be resorted to ; for instance, it should never be done where the pre- 
sentation is not natural, unless we mean to proceed immediately to artificial delivery. 
And if this should be deemed expedient, there can be no propriety in giving the ergot, 
for the less opposed we are by pain during turning, the better. It, therefore, also- 
follows, that this substance should not be given in cases where it will be certainly ne- 
cessary to turn ; especially if the waters have Ions: been drained off. 



OF THE SECALE CORNUTUM, OR ERGOT. 541 

feel a reluctance to adopt this remedy, in the cases under considera- 
tion, as reasoning appears to be decidedly against its employment. 

1760. Let me be borne with a little longer, as this subject is one of 
high interest in every point of view : for a placental presentation is 
always one of great danger, even under the best management ; and it 
is almost necessarily fatal under bad. Do not let me be supposed, 
in this investigation, to substitute reasoning for facts ; for the very 
contrary would be my wish. Bat until I shall be in possession of 
unequivocal testimony in its favour, I shall remain at least, doubtful 
of the safety of employing it. 

1761. I have in so many words declared, that reasoning is against 
the use of the ergot, in the unavoidable hemorrhage ; I will now en- 
deavour to show this to be the case. The primary object in all cases 
of hemorrhage is to arrest the bleeding: now, in the cases in ques- 
tion, this is particularly necessary, if it be even temporarily : and for 
this purpose a variety of means are resorted to;* but this cannot be 
done absolutely, but by delivery. Why should delivery be the only 
certain remedy in this case? For several reasons ; first, because a 
temporary suspension of the bleeding is no security against its return; 
as the very mechanism of labour causes the placenta to detach itself 
from the mouth of the uterus ; and when this takes place, hemorrhage 
must ensue ; and this in the exact ratio to the extent of the sepa- 
ration. Secondly, this being the case, it follows, that whatever tends 
to increase the separation will necessarily augment the bleeding — 
uterine contractions have this tendency ; and the ergot is almost cer- 
tain to provoke, or increase, uterine contraction ; consequently, to 
increase hemorrhage. Thirdly, because pains may exist for some 
time, without the os uteri being disposed to yield ; yet during the re- 
turn of each pain, the hemorrhage is increased ; consequently, if the 
uterine contractions be increased in force or frequency by any agency 
whatever, and the mouth of the uterus does not dilate in the same 
proportion, mischief, instead of good, must be the result. 

1762. For these reasons, we are of opinion, that the ergot should 
not be used in cases of placental presentations; as a general practice ; 
and, if used at all, it should only be when the os uteri is well dilated, 
or easily dilatable. In such cases it may be occasionally useful, by 
urging the uterus to brisker contractions, and thus effect the delivery 
of the child as speedily, perhaps as when turning is had recourse to ; 
especially if this must be attempted by the inexperienced practi- 
tioner. 

1763. The ergot may be used with a fair prospect of success, 
when the head of the child has been left within the cavity of the 
uterus, after the delivery of its body, when no objection can arise 
from the unhealthy condition of the pelvis. 

1764. I have also derived much advantage in several cases of 
menorrhagia ; where the long continuance of the disease, rather than 

* See Chapter on Uterine Hemorrhage from the location of the placet. ta. 



542 OF THE SECALE CORNUTUM, OR ERGOT. 

the immediate excess of the quantity discharged, rendered it impor- 
tant it should be arrested. I have given in such cases,, three grains 
three times a day, in the form of a pill, and continued it for some 
time. 

1765. It may also be useful in cases of polypi, when it shall be 
desirable to force the substances beyond the neck of the uterus, for 
the purpose of applying a ligature, or with a view to their excision. I 
have some time since suggested its probable usefulness in hydatids 
of the uterus ;* and its value in such cases has been in part realized 
by Dr. Macgill.f 

* See Treatise on the Diseases of Females, Chapter on "Hydatids of the Uterus,' 1 
by the Author. 

f See his interesting case in the American Journal of Medical Sciences, No, L 
November, 1827, and, also, in the chapter just referred to. 



FJLol, 




( 543 ) 



EXPLANATION OF PLATE I. 

(from baudelocque.) 

A, A, A, A, The ossa iliac properly so called, 
a, a, The iliac fossae, 
bb, bb, The angle which divides transversely and obliquely 
from behind forward, the internal face of the os ilium 
into two parts, and which makes part of the brim of 
the pelvis, 
cc, cc, The cristas of the ossa ilia, 
e, e, The anterior superior spine of the ossa ilia, 
f, f, The angle formed by the internal lip of the crista of 
the ilium towards the extremity of its anterior two- 
thirds, and to which is attached a ligament inserted 
at the other end in the transverse apophysis of the 
last lumbar vertebra, 
g, g, The inferior angle of the os ilium, which makes part 
of the acetabulum. 

B, B, The os ischium. 

h, h, The tuberosities of the ischia. 

i, i, The branches of the ischia. 
k, k, The posterior parts of the ossa ischia, which make 
parts of the acetabula. 

C, C, The bodies of the ossa pubis. 
1, 1, The angles of the ossa pubis. 

m, m, The posterior extremities of the ossa pubis, which 
make part of the acetabula. 
n, n, The descending branches of the ossa pubis, which 
unite with those of the ischia. 
D, D, D, The os sacrum. 
1, 2, 3, 4, The anterior sacral holes, 
o, o, o, The base of the sacrum. 



( 544 ) 

p, p, The sides of the sacrum. 

E, The coccyx. 

F, The lumbar vertebra. 

r, r, The transverse apophyses of the vertebra. 

s, s, The ligaments which go from the transverse apophy- 
ses of the last vertebra, to the angle of the internal 
lips of the crystse of the ilia, indicated by the letters 

f,f. 

t, t, Two other ligaments which descend from the same 
apophyses to the superior edge of the sacro-iliac 
symphyses. 
G, G, The femurs or thigh bones. 
V, V, The heads of the femurs received into the aceta- 

bula. 
u, u, The foramina ovalia. 

Symphyses of the bones of the pelvis. 

H, The symphysis of the ossa pubis. 
I, I, The sacro-iliac symphyses. 
K, The sacro-vertebral symphysis. 



FL.M, 




545 ) 



EXPLANATION OF PLATE II. 

This figure represents the entrance of a well-formed pelvis, 
a, a, The iliac fossae. 

b, The sacro-vertebral angle, or the projection of the 

sacrum. 

c, The lastiumbar vertebra. 

d, d, The lateral parts of the base of the sacrum. 

e, e, The sacro-iliac symphyses. 

f, f, The parts over the acetabula. 
g, The symphysis of the pubes. 

The lines indicate the different diameters of the superior strait. 

A, B, The antero-posterior, or little diameter. 

C, D, The transverse, or great diameter. 

E, F, The oblique diameter, which extends from the left 

acetabulum to the right sacro-iliac junction. 
G, H, The oblique diameter, which goes from the right 

acetabulum to the left sacro-iliac junction. 



47 



( 546 ) 



EXPLANATION OF PLATE III. 

This figure represents the inferior strait of a well-formed pelvis. 

a, a, The external faces of the os ilia. 

b, b, The anterior superior spines of the ossa ilia. 

c, c, The anterior inferior spines of the ossa ilia. 

d, d, The acetabula. 

e, e, The foramina ovalia, with the obturator ligaments. 
f, f, The ischiatic tuberosities. 

g, g, The ossa pubis. 

h, h, The branches of the ossa pubis and ischia united. 

i, i, The sacrum. 

k, The coccyx. 
1, 1, The sacro-ischiatic ligaments. 

m, The symphysis of the pubes. 
n, n, The arch of the pubes. 

The lines indicate the diameters of the inferior strait. 

A, A, The antero-posterior diameter or great diameter. 

B, B, The transverse or small diameter. 
C, C, D, D, The oblique diameters. 



ri.Aii: in 




rL^LTE IV 




( 547 



EXPLANATION OF PLATE IV 



This figure represents a deformed pelvis. 

a, a, The ossa ilia. 

b, b, The ossa pubis. 

c, c, The ossa ischia. 

d,d, d, The last lumbar vertebra. 

e, The projection of the sacrum, 
f, f, The sacro-iliac symphysis, 
g, The symphysis of the pubes. 
h, h, The foramina ovalia, 
1, i, The branches of the ossa pubis and ischia, which form the 

anterior arch of the pelvis. 
k, k, The acetabula. 

The lines indicate the diameters of the superior strait. 

\. A, The antero-posterior diameter; its natural width reduced to 
fourteen or fifteen lines, or so many portions, twelve making 
an inch. 

B, B, The transverse diameter — its length, in this subject, four 

inches, ten lines. 

C, C, The distance from the projection of the sacrum, to that of 

the margin which answers to the left acetabulum, thirteen 
lines. 

D, D, The distance from the same point of the sacrum, to that ot 

the margin which answers to the right acetabulum, twenty 
lines. • 



( 548 



EXPLANATION OF PLATE V. 

This plate is intended to represent the first presentation of the ver- 
tex, or where the posterior fontanelle is behind the left acetabulum, 
and the anterior to the right sacro-iliac symphysis. In this position 
the head offers itself diagonally to the opening of the superior strait ; 
the left ear will correspond with the right foramen ovale, and the 
chin is pressed against the sternum. 

a, The left acetabulum. 

b, b, The symphysis of the pubes. 

c, c, The oval foramens. 

d, The spine of the ilium. 

e, The uterus. 

f, The dots indicating the posterior fontanelle. 

g, The anterior fontanelle, or right sacro-iliac symphysis* 
h, The arch of the pubes. 

i, i, The tubers of the ischia. 
k, k, The margin of the pelvis, or superior strait. 

For the mechanism of this labour, see page 193. 
For the mode of turning in it, see page 233. 
For the application of the forceps, see page 258, par. 816, 
and following. 



,"/,.! . 




Ji'InWlL 




( 549 ) 



EXPLANATION OF PLATE VI., OR SECOND PRESEN- 
TATION. 



a, The right acetabulum. 

b, The symphysis of the pubes. 

c, Left foramen ovale. 

d, Spine of the right ilium. 

e, The uterus. 

f, Dots presenting the site of the posterior fontanelle. 

g, Anterior fontanelle, or left sacro-iliac symphysis, 
h, Arch of the pubes. 

i, Tuber of the left ilium. 

For the mechanism of this labour, see page 195. 
For the mode of turning, see page 234. 
For the application of the forceps, see page 592, par. 819, 
and following. 



47< 



( 550 ) 



EXPLANATION OF PLATE VII., OR THIRD PRESEN- 

TATION. 



a, Left acetabulum, 
b, b, Symphyses pubes. 

c, Left foramen ovale. 

d, Spine of the right ilium. 

e, The uterus. 

f, The posterior fontanelle, indicated by the dots. 

g, Left sacro-iliae symphysis, 
h, Arch of the pubes. 

i, Tuber of the left ischium. 

For the mechanism of this labour, see page 195. 
For the mode of turning, see page 234. 
For the application of the forceps, see page 259, par. 820, 
and following, 



/'L "17/. 




J7r.ru 




( 551 ) 



EXPLANATION OF PLATE VIII., OR FOURTH PRE- 
SENTATION. 

a, Left Acetabulum. 
b, b, Symphysis pubis. 

c, Left foramen ovale. 

d, Spine of the ilium. 

e, The uterus. 

f, Anterior fontanelle indicated by the dots, 
g, Right sacro-iliac symphysis. 

h, Arch of the pubes. 
i, Left tuber of the ischium. 

For the mechanism of this labour, see page 195. 
For the mode of turning, see page 235. 
For the application of the forceps, see page 260, par. 824, 
and following. 



( 552 ) 



EXPLANATION OF PLATE IX., OR FIFTH PRESENTA- 
TION. 



a, Right acetabulum. 

b, Symphysis pubis. 

c, Right foramen ovale. 

d, Spine of the ilium. 

e, The uterus. 

f, Anterior fontanelle, indicated by the dots. 

g, Left sacro-iliac symphysis, 
h, Arch of the pubes. 

i, Tuber of the ischium, 
k, k, Margin of the pelvis. 

For the mechanism of this labour, see page 199. 
For the mode of turning, see page 235. 
For the application of the forceps, see page 260, par. 825, 
and following. 



77,, IK. 




FL.X. 




( 553 ) 



EXPLANATION OF PLATE X., OR SIXTH PRESEN 
TATION. 



a, Right acetabulum, 
b, b, Symphysis pubis. 

c, Foramen ovale. 

d, Spine of the ilium. 

e, The uterus. 

f, Anterior fontanelle behind the symphysis pubes, as indicated 

by the dots. 

g, Left sacro-iliac symphysis. 
h, Arch of the pubes. 

i, Tuber of left ischium. 

For the mechanism of this labour, see page 199. 
For the mode of turning, see page 235. 

For the application of the forceps, see page 261, par. 828, and 
following. 



( 554 ) 



EXPLANATION OF PLATE XL 

Fig. I. 

This plate represents the middle-sized pessary. 
From a, a, Two inches and four-tenths. 

b, A central hole to permit any discharges to pass, three- 
tenths of an inch in width. 
c, c, An excavation for the neck of the uterus to lie in, 
when applied. 

Fig. II. 

Is a central section of the same pessary. 

a, a, Represents the internal cavity of the pessary. 

b, b, Represents the depth of the excavation of c, c, of Fig. I. 

5J tenths of an inch deep, 
c, A section of the central hole, b, of Fig. 1. 



Fig 2. 



/'/,.. \7 






Suli.m through (he Centre. 



I 'i •>■.!. 



/%/// 



( 555 ) 



EXPLANATION OF PLATE XII. 



EXPLANATION OF THE FORCEPS OF PROFESSOR SIEBOLD. 

I have been favoured, by the politeness of Dr. Eberie, with a 
sight of Professor Siebold's forceps. In their general form and 
size, they differ but little from the forceps of Baudelocque ; they are 
rather longer in the clams, and a little more curved, as will be seen 
by examining the plates. 

What I value in them is, their very ingenious mode of locking : 
I am persuaded this has a decided advantage in some positions of 
the head, and will contribute to the success of application. 

Fig. I. 

a, The top of the screw, which serves to unite the blades. 

b, The head of the shoulders of the screw, which is received a 
very small way into the countersink f, fig. 2. 

c, The conical body of the screw, which is received into the ex- 
cavation g, fig. 2. 

d, The cut part of the screw, which passes into the female screw 
cut in the body of the blade of the forceps. 

e, The head, or but, against which the lower extremity of the 
screw is received. 

Fig. II. 

f, The countersink for receiving the shoulder b, fig. 1. 

g, The conical excavation for the reception of c, fig. 1. 

Fig. III. 

The forceps united and reduced to one-half the proper size, 
h, h, The manner in which the screw unites the blades, 
i, i, The turned extremities of the handles, which serve, like those 
of Baudelocque, as blunt-hooks. 



( 556 ) 



EXPLANATION OF PLATE XIII. 



The forceps represented in Plate XIII. are reduced two-thirds from 
the proper size — they are called the long French Forceps, orBaude- 
locque's forceps, though they differ a little from them, but not ma- 
terially. These instruments are well made by Mr. John Rorer, No. 
26, North Sixth Street, from a Paris Pattern. 



PLAT/: A'/// 





s 



#» 



plati: jam 



PLATE XK 




( 557 ) 



EXPLANATION OF PLATE XIV. 



a, The body of the uterus, reduced to about half its natural size 

after labour. 

b, The hollow formed by the depression of the fundus. 

c, The neck of the uterus contracted. 

d, The os tincae. 

e, e, The membranous expansions by which the uterus is connected 
with the pelvis. 



48 



( 558 ) 



EXPLANATION OF PLATE XV. 

a, The body of the uterus inverted and reduced to about half 

its natural size after labour. 

b, The neck contracting firmly on the protruding fundus. 

c, The fundus escaping through the os uteri. 

d, The depression formed by the inversion of the fundus. 

e, e, The membranous expansions which connect the uterus with 
the pelvis. 



TLATK JT7. 




( 559 ) 



EXPLANATION OF PLATE XVI. 



a, a, a, The fundus and body of the uterus escaping through the os 
uteri, reduced to about half its natural size after labour. 

b, The neck of the uterus firmly embracing the inferior portion 

of the body. 

c, The vacancy left at the upper portion of the neck of the 

uterus, 
d, d, d, The connecting membranous expansions of the uterus. 



( 560 ) 



EXPLANATION OF PLATE XVII. 

a, a. The body and fundus of the uterus.* 

b, The neck of the uterus inverted with the body and fundus. 

c, The os uteri looking into the abdomen. 

d, d, The connecting membranous expansions of the uterus. 

* In making the above drawings, our only aim was to make the mechanism of 
inversion clearly understood. We have, therefore, divested the uterus of all its ap- 
purtenances, except that by which it is connected with the vagina, that the figures 
need not be confused. For the same reason we have represented the uterus delivered 
of the placenta. 



PLATE Jan. 







FINITE AYJlf. 



d \ 




( 561 ) 



FXPLANATION OF PLATE XVIII. 



Fig. I. 

a, a, a, The umbilical cord prolapsed before the presenting part of 
the child. 



Fig. II. 

a, a, An elastic gum catheter of the size called No. 8, reduced 
to one half its breadth and length. 

b, The stilet. 

c, The eye of the catheter. 

d, A loop of riband or tape passed over the cord, both ex- 

tremities of which are made to pass through the eye, c, 
and descend a little below the external extremity of the 
catheter. It will be seen by this arrangement, that the 
upper extremity of the catheter can be put in contact with 
the cord, by drawing the ends of the riband without, and 
gently pressing the instrument upward ; and when there, 
it may be kept in that situation, by forcing the point of 
the stilet upwards ; or the loop, can be loosened by with- 
drawing the stilet, or ceasing to draw upon the external 
ends of the riband. 
e, e, The extremities of the riband. 



Fig. III. 

a, a, The body of the catheter. 

b, The stilet. 

c, The eye of the catheter, through which the riband passes. 

d, A knot tied on the cord. 

e, e, The external extremities of the riband. 



V. 



( 562 ) 

It will readily be perceived that if the ends of the riband in fig. 
II. be drawn, the cord and the extremity of the catheter will be 
brought in contact, and if it be desirable to fix it in this position, it 
can be done instantly by forcing the stilet home; and if it be neces- 
sary to take off" the pressure from the cord, it can be readily effected 
by ag ain withdrawing the stilet a short distance. Whereas the 
ligature in fig. III. is permanent, and will consequently maintain a 
uniform pressure upon the cord, and may even arrest the circulation 
within it. If it be necessary to withdraw the catheter after the loop 
is returned, it can be done in either case with equal facility by draw- 
ing the stilet so as to disengage its point from the riband, where it 
passes through the eye of the catheter, and then removing the ca- 
theter itself. There will be, however, this difference in the situa- 
tions of the ligatures ; that of fig. II. will be without compression on 
the cord ; while that of fig. III. will constantly remain the same. 



DIRECTIONS FOR PLACING THE PLATES. 

The plates are to be placed at the end of the book, making them 
face their explanations. 



THE END. 



LIBRARY OF CONGRESS 



021 064 107 5 




(MM- 

BOB 



